Ketamine is an old anesthesia drug with psychedelic qualities, and it has been getting a lot of attention for its ability to help with conditions like treatment-resistant depression, post-traumatic stress disorder and anxiety. Ketamine is also being used off-label to treat existential suffering at the end of life.
David Luery almost missed out on love more than 50 years ago.
“I always like to tell people we met on a blind date that I didn't turn up for,” he said as he laughed.
His date, Nicolette, was the forgiving type.
“And six weeks later, we were engaged,” he said.
That was in 1970. In 2017, David and Nick, as he calls her, retired and moved to Tucson from the Midwest. But even before the move, “I started noticing that she would misplace things or lose things. And there was a family history. Her mother and two maternal uncles had Alzheimer's.”
So they both knew it was a possibility. But the couple never really talked about it. Reality hit in 2019 when they were flying back from a trip to London to see Eric Clapton perform.
“And we're in the plane, and she turns to me and says, 'Is my daughter going to pick us up at the airport?' We never had children," said David.
Nick was diagnosed with Alzheimer's disease a year later. As the disease progressed, David needed help with both her physical care and emotions. Nick began struggling with intense crying episodes.
“And I remember calling David on the phone, and he was actually out with Nick at the time, driving her around, because that's what he would do when she would cry, to try to stop the crying episodes,” said Melissa Koon, a nurse practitioner and owner of Elder Care at Home in Tucson, which provides in-home palliative and dementia care.
And she could hear his desperation. Koon says after she got involved in Nick’s case they tried several medications. Nothing helped.
But Koon had been using ketamine on other patients for more than a decade.
“In fact, the first patient I had that I used it for was a lady who had neurocortical basal degeneration, where she was basically locked in," said Koon.
That woman, who was in hospice, was aware of everything, but couldn't move or talk.
“And she would cry all through the day. It was very disturbing, and we tried several different medicines, and none of them worked," Koon said.
So, Koon tried ketamine, which can create a psychedelic effect depending on the dosage. And the crying stopped.
Koon says they used ketamine in other cases and saw rapid results in the hospice setting.
“And in that environment, you don’t have long to go through a lot of psychotherapy and get to where you need to be with diagnosis. You need to get resolution quickly," said Koon.
A brave new world
Joe Solien is the vice president of clinical services at Tempe-based One Point Patient Care, which serves 700 hospices across the country, including the hospice where Koon’s patient was residing.
Since then, he says that hospice has had several success stories — and because of ketamine, those patients had what amounted to a “good death,” because their last weeks were more comfortable.
“Depression is everywhere in hospice, pain is everywhere in hospice. If you're not thinking about ketamine, you're just not working with a whole tool set,” said Solien.
But here’s where the story takes a turn — and why Solien calls Koon “brave.”
“She really has driven this to new places and found some new areas where, specifically in different behavioral and psychological symptoms of dementia, has found ketamine to be very beneficial," Solien said.
Like in Nick’s case. Koon hypothesized that Nick had some awareness of what was happening because her crying episodes often occurred when she was being bathed, dressed or toileted.
Laura Aylmer is a licensed clinical social worker with Elder Health and works with Koon. She says using ketamine like this both helps the person experiencing distress, as well as the caregiver, who is watching it all unfold.
“It's a very helpless time. There's a lot of uncertainty, and so the use of ketamine is helping to manage the symptoms, and it's also allowing for expression of feeling."Laura Aylmer, Elder Health licensed clinical social worker
“It's a very helpless time. There's a lot of uncertainty, and so the use of ketamine is helping to manage the symptoms, and it's also allowing for expression of feeling. So unlike something else that might be coming in to really cover up the pain or the emotion,” Aylmer said —Like the medications lorazepam or morphine, which also happen to be the two top prescribed drugs in hospice — Ketamine, "doesn't cover up all the feelings."
A healing journey
Administering ketamine isn’t difficult, says Koon. Sometimes it's given orally, other times through IV or injection. But it does require medical supervision — and a play list curated specifically for Nick.
“So part of our protocol for ketamine is the use of music therapy, because that's something that David could use even when we weren't there doing the ketamine," said Koon.
As the music plays, Koon administers the injection. She and Aylmer sit with Nick for the entire hour.
“We observed her for an hour. During that time, we watched her aspirations, her heart rate, her vocal [and] facial expressions. And we make notes throughout the playlist when things happen and how she reacts,” said Koon. “And that lets us know what things might be making her upset or where we are in the peaceful area.”
Sometimes the music is more intense, and that's where her anger or frustration might come through. But the goal, says Koon, is peace and acceptance that she’s inhabiting what’s called the "liminal space" — somewhere between living and dying.
The liminal space
Ketamine is not often used in the palliative care setting or even in hospice. Still, it’s gaining traction for its ability to help ease the existential suffering that can be experienced at the end of life.
“Yeah, I think that existential anguish is very real, and whether it's coming through in verbal or nonverbal ways,” Like Nick's crying, “it's there,” said Laura Aylmer.
Aylmer says Nick was in the liminal space when she was being treated with ketamine.
“Where someone is stretched between what they can remember and the sense of losing the fact that they won't be able to remember. They're stretched between living and dying," Aylmer said.
Facing the wave
And ketamine sits right in the middle of these paradoxes, Aylmer said. So imagine standing in the ocean as a massive wave or death is coming and the beach, which represents the attachment to our human experience — is not accessible. That's the liminal space.
“And that's where a lot of people are, whether it's with dementia or palliative or hospice that you're using ketamine,” said Koon. “So you're trying to find peace — here. And that's a scary place.”
Ketamine appears to dissolve that fear. And the results can come quickly. David says there were two factors at play when it came to Nick’s crying episodes: frequency and severity. After the first session, her spells were shorter and less intense, but still frequent. So they increased the dose.
“But after the second injection, both of them were declining. And that just continued throughout the ketamine therapy. So, my comfort was coming from the fact that Nick had less distress," said David.
The science of psychedelics
What Nick possibly experienced, that existential suffering, is more of an umbrella term according to Brian Anderson, a psychiatrist and faculty member in the Department of Psychiatry at University of California, San Francisco.
Anderson studies “demoralization,” or the loss of meaning and purpose, that affects around a third of people with a life-limiting illness.
“It's a pretty well-characterized syndrome within existential distress that we can measure, and we can see what are the impacts of the interventions we're offering to our patients,” said Anderson.
“It's a pretty well-characterized syndrome within existential distress that we can measure, and we can see what are the impacts of the interventions we're offering to our patients.”Brian Anderson, Department of Psychiatry at University of California, San Francisco.
And those treatments typically involve talk therapy. Ketamine, he says, isn’t a classic psychedelic, but it can cause altered states of consciousness. At the same time, there’s a renewed interest in psychedelics like psilocybin, or ‘magic mushrooms,' to treat certain mental health conditions.
In fact, Anderson says these therapies go back decades.
“But the way we're using certain drugs now — I'll come back to treating existential distress — these drugs seem to, for many people, cause a sort of transcendent experience that puts them in touch with their existential concerns and helps them deal with things regarding grief and loss, and the meaning and purpose of their life. This has gotten a lot more attention," said Anderson.
And is leading to more academic research, including Anderson’s own study, which aims to look at the effectiveness of both ketamine and psilocybin, plus talk therapy in patients with a terminal condition like cancer.
“If we can help participants in our study have a greater sense of peace, some meaning about what they're going through, and what their life has been for them and meant for other people, and feeling like they have some agency, that’s a great outcome," Anderson said.
Even if it is for a short duration. For David Luery’s wife, Nick, she only needed seven ketamine treatments over the course of six months. Throughout the last 10 months of her life — she died in 2023 — she didn’t require any ketamine. Her anguish appeared to have subsided.
“And I truly believe that Nick was essentially happy to the end of her life. And I think that with a lot of help, I think Nick was able to live as good a quality of life as she could have," said David.
EDITOR'S NOTE: This story has been updated to correct the spelling of David Luery's name.
