Another is the accumulation of bronchial mucus as patients become weaker, experience reduced consciousness (caused by the disease itself or exacerbated by opioid, hypnotic or sedative drugs), and lose their swallowing and cough reflexes (National Institute for Health and Care Excellence (NICE), 2021 Kolb et al 2018) and, with them, their ability to clear secretions from the trachea and oropharynx (Bennett et al, 2002). One cause of death rattle is the accumulation of saliva, of which an average of 2L is produced daily by healthy individuals (Rumbold, 2011). This is disappointing for both relatives and professionals alike (Fielding and Long, 2014), and treatments may be more harmful than beneficial for patients (Campbell and Yarandi, 2013). The effectiveness of pharmacological and non-drug treatments, use of which differs between institutions (NICE, 2021), is inconsistent and often fails to resolve the symptom (Kolb et al, 2018). Hence, treatment for death rattle is often started by clinicians concerned about the distress experienced by others – rather than by the patient – who feel obliged to intervene (Fielding and Long 2014 Hirsch 2011). Those most distressed by the sound of death rattle make the most disturbing interpretations (Shimizu et al, 2014), and may remain distressed years later when recalling the experience of hearing it (Wee and Hillier, 2008). It can certainly distress other patients within earshot (Baillie et al, 2018), as well as relatives and friends of the dying, who may fear that their loved one is suffering, in pain, gagging, choking, suffocating or even drowning (Watts et al 2019 Watson et al 2016 Lokker et al, 2014). It is impossible to know how a dying person may experience death rattle it is generally thought unlikely to cause distress for patients who are unconscious (Clark and Butler, 2009), but it may involve dyspnoea and restlessness for some. The huge variation is likely due to inconsistent terminology, mainly retrospective data collection and a lack of standardised, reliable, validated or objective measurements of death rattle or its intensity (where documented at all), with consequent subjectivity of evaluation and inevitable inter-observer bias (Kolb et al, 2018 Fielding and Long, 2014 Hirsch, 2011 Clark and Butler, 2009 Wee and Hillier, 2008). The international incidence of death rattle is reported to be anywhere from 12% (Kolb et al, 2018) to 92% (NICE, 2021). However, death may not occur for several days (Wildiers and Menten, 2002) – with death rattle being distressing for the patients’ relatives (Van Esch et al, 2020). When death rattle occurs, it precedes death within 24 hours for 48% of patients and within 48 hours for 75% of patients for others. Alongside pain, agitation, dyspnoea and nausea (Kolb et al, 2018), death rattle is among the commonest symptoms in the dying, and an “audible declaration of the dying process” (Bennett, 1996). ‘Death rattle’ is the unpleasant gurgling, bubbling or rattling often heard persistently during breathing in the last days of life (National Institute for Health and Care Excellence (NICE), 2021 Davies et al, 2015 Wee and Hillier, 2008). Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser).This article has been double-blind peer reviewed.This article discusses the rationale around current management of death rattle and whether it is in the best interests of the patient.Ĭitation: Beland P (2022) What is the evidence for treating ‘death rattle’ at end of life? Nursing Times 118: 5.Īuthor: Paul Beland is hospice specialist nurse, St Nicholas Hospice Care, Bury St Edmunds. There is little evidence for the superiority of one drug over another or that any pharmacological or nursing intervention is better than doing nothing. Although antimuscarinic drugs appear more likely to be effective if used as soon as death rattle begins, they also have adverse effects, which are more likely to be detrimental if the drugs are used too soon. Although not thought to cause distress to patients when they are dying, death rattle is undoubtedly distressing for patients’ relatives and friends, and sometimes for health professionals. ‘Death rattle’ is the noisy, rattling breathing that is common in patients at the end of life.
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