Sunday, April 25, 2010

Death Rattle 201

While I was in nursing school, I wrote on this blog about death rattle. Family members responses to that post revealed a lack of reassurance provided from the explanation. And some nurses I worked with reported that the interventions typically suggested (turning and repositioning and anticholinergic medications) sometimes either had no effect or even made the sound worse. So... I decided to do my Master's thesis on the death rattle (often referred to as "excessive respiratory secretions" in the medical field). Here is a brief summary of my dissertation.

Death rattle occurs in 51% to 70% of patients within the last 48 to 57 hours of life (Lichter & Hunt, 1990; Morita, Tsunoda, Inoue & Chihara, 1998; Bausewein & Twycross, 1995; Power & Kearney, 1992).

Anticholinergic medications, which are typically used to treat death rattle, block the parasympathetic innervation of the salivary glands by inhibiting muscarinic actions of acetylcholine on autonomic effects innervated by post-ganglionic cholinergic neurons thus reducing the production of saliva (Hockstein, 2004; Springhouse, 2002). As the death rattle does not always respond to these interventions, Bennett conducted further research into this phenomenon and came up with the conclusion that there is more than one type of death rattle.

Physiological Theory: Causes of Death Rattle

Bennett (1996) identified two different types of death rattle. Type I is caused by an accumulation of salivary secretions when swallowing reflexes are inhibited and type II is caused by an accumulation of bronchial secretions in patients too weak to cough effectively (Bennett, 1996).

Salivary Secretions

Salivary glands have an average output of 1000 to 1500 mL per day (Marieb, 1998). Salivation with eating is controlled by the parasympathetic division of the autonomic nervous system and the facial (CNVII) and glossopharyngeal (CNIX) cranial nerves; however, the sympathetic nervous system causes continuous release of a thick mucin-rich saliva irrespective of digestion (Marieb, 1998). Both the parasympathetic and sympathetic nervous systems have nerve endings in the salivary glands (Zeppetella, 1999). The constriction of blood vessels serving the salivary glands inhibits the release of saliva through the sympathetic system. Dehydration also inhibits salivation because low blood volume results in reduced filtration pressure at the capillary beds of the salivary glands (Marieb, 1998). There is no evidence, however, that salivary secretion decreases nor continues at the same rate in the end of life.

Impaired Swallow and Cough Reflexes

Swallowing and coughing reflexes are regulated by the autonomic reflex enter of the medulla (Marieb, 1998). The involuntary component to swallowing (pharyngeal-esophageal phase) is controlled by the vagus nerve (Marieb, 1998). Although many research articles empirically support the theory that the coughing and swallowing reflexes cease at the end of life, physiological explanations for this phenomenon are as of yet unknown (Bennett, 1996, Ellershaw, et. al., 1995, MacLeod, 2002).

Current Management Guidelines

Current practice guidelines for the management of death rattle include repositioning the patient to mobilize the secretions, anticholinergics, suctioning and reassurance or education (Poor & Poirrier, 2001; Enck, 2002; Doyle, Hanks & MacDonald 1998; Hughes, Wilcock & Corcoran, 1996; Spruyt & Kausae, 1998; Dudgeon, 2001). Morphine and midazolam have also been suggested concomitantly with anticholinergics to increase sedation and prevent central nervous system excitement caused by anticholinergics (Enck, 2002; Doyle, Hanks & MacDonald, 1998); morphine may also improve the frequency of death rattle by decreasing the respiratory rate. No research has been completed to evaluate the effectiveness of repositioning, suctioning nor education as management strategies for the distress caused by death rattle.

Suctioning may not be an effective means of treating death rattle for multiple reasons. For one, the secretions are pooling farther in the hypopharynx or the bronchial tree than an oral or Yankauer suction can reach. Even when a nasal trumpet is used to suction farther back in the nasooropharynx, repeated suctioning causes local trauma to the mucous membranes. This leads to inflammation and swelling, which eventually complicates further suctioning. Death rattle secretions may need to be suctioned as frequently as every two hours. Based on my clinical observations, after as few as four or five episodes of suctioning, edema may occur and may occlude the airway, preventing further suctioning. Suctioning is also thought by some to be undignified for the patient and may cause the patient distress if the patient is alert or semi-conscious. Nevertheless, it is frequently advocated in literature (Poor & Poirrier, 2001; Enck, 2002; Doyle, Hanks & MacDonald 1998; Hughes, Wilcock & Corcoran, 1996; Spruyt & Kausae, 1998).

In practice, many palliative care units and hospices limit intravenous fluids. The rationale for this practice is that intravenous fluids are forcing fluids into the body that the body is unable to utilize. Dying patients frequently have decreased serum protein levels, which shifts the plasma’s osmotic pressure; this causes fluid to leak from the vasculature, causing edema (Guyton, 1996). These fluids may collect in the lungs, the ankles and the oropharynx.

Type II Death Rattle

When anticholinergics are used consistently, yet the death rattle continues, there may be another underlying cause. These cases have been referred to by Bennett (1996); Morita, Tsunoda, Inoue and Chihara (2000); and Wildiers and Menten (2002) as type II death rattle. In most cases, it is difficult to distinguish between the two types because scientific investigation is rarely indicated in the last days of life. However, some causes may be identified and thus treated appropriately.

Treatment Recommendations

Identify each dying patient’s particular risk factors for developing death rattle to assess whether type I or type II death rattle is most likely to occur.

Family members should be encouraged to report any audible sounds to their health care provider as soon as they notice it to ensure early intervention.

Consider prophylactically treating patients at increased risk for type I death rattle by repositioning the patient every two hours and by applying a scopolamine patch. Simultaneously, the frequency of mouth care must be increased to every one to two hours in order to maintain the integrity of the oral mucosa with the reduction of salivary secretions.

Risk factors include: prolonged dying phase

If scopolamine is ineffective in preventing the occurrence of type I death rattle, administer an additional anticholinergic around-the-clock for continuous coverage, such as atropine ophthalmic 1% 1 drop sublingually every 2 hours.

If the death rattle does not respond to the second anticholinergic, treat the patient empirically for possible type II death rattle causes (CHF, pneumonia, pulmonary tumor). If patient is known to have heart failure, treat with a diuretic. If the cause is suspicious for neurogenic pulmonary edema, treat with osmotic diuretics (i.e., mannitol), morphine (to decrease respirations), and/or corticosteroids (to reduce intracranial pressure). If the patient’s secretions are malodorous, suspect pneumonia and consider giving a single dose of Ceftriaxone. However, it should be noted that there are challenges in performing some of these interventions outside of a hospital setting.

Evidence has repeatedly suggested that death rattle is distressing to patients, family members and nursing staff and needs to be adequately managed in dying patients. Our goal is to provide for a “good,” peaceful, dignified death, one in which family members are assured of their loved ones’ comfort. Therefore it is imperative that we, as health care providers, address the treatment of death rattle.


W. Brian Byrd MD said...

Thank you for that nice summary. I learned a lot and will pass some of it one to my clinical team.

Ivy and Haley said...
This comment has been removed by a blog administrator.
Anonymous said...

I appreciate your work. I am watching my first hospice patient in his last hours struggle with what I believe to be the type II rattle, but the hospice doctors don't treat it more than giving atropine and repositioning. I don't think the patient is as comfortable as he could be if the hospice doctors were to treat the type II rattle. I thought that comfort was the goal, not packaged standards of care...

Sarah said...

Thank you for sharing your research. Very informative and useful in regards to the unit I work on. Not many sources available in regards to the Death Rattle, thank you again.

. said...

Thank you for sharing. I am a chaplain and you are helping me so much.

God bless you


Anonymous said...

Thank you for sharing my grandmother passed this morning. Your explanation helped clear up questions I had...blessyou.

Geosomin said...

That's really interesting. I always wondered what caused that in the older patients my Mum worked with before they passed on.


Anonymous said...

thank for this information. Very helpful.

Anonymous said...

Very helpful. It has been such an interesting experience dealing with my mothers long illness in the last year. I do wish that the "death rattle" was explained better to people. I had heard the term, but always thought it was the very last few breaths. Don't remember it in movies, etc. It would have been reassuring in an odd way to know that the presence of the sound meant that it was just a few hours to go. I left for sleep after a long night... thank goodness a remaining caregiver was there to let me know they thought the end was near so that I could return and fulfill my mothers wish to have me hold her hand...

Anonymous said...

I found your post on "Death Rattle 201" both fascinating and frustrating. You point out that a patient experiencing a death rattle in their final days is disturbing to the patient, family members, and staff, and should be addressed in order to give them a dignified end of life. I whole heartedly agree that hospice patients, or anyone else, deserve a dignified death. But disturbing does not preclude a dignified death. I also work in hospice. Death is plain and simply disturbing. It is the loss of a beloved family member, friend, and loved one. The death rattle in my opinion is an audible expression of that. What you are describing is similar to the way we pretty up the dead by embalming them and trying to make them look alive. Both are things we do to avoid actually making contact with the death process. I respectfully disagree with your post. And instead suggest we learn to sit with the death rattle, and allow it to reverberate through us as does the sadness we feel when we experience a loss through death.

Anonymous said...

The No-Bite V is an amazing new device that eliminates the death rattle. You never have to nasotracheal suction again! I contacted them and they sent out a rep to my hospice with free samples. I've been a RN for 11 years and I am very impressed!!!

Check out:

Anonymous said...

"Evidence has repeatedly suggested that death rattle is distressing to patients, family members and nursing staff and needs to be adequately managed in dying patients."

--natural to patients

--family member's feelings are secondary

--feelings of the nursing staff need not be of concern clinically and should have been addressed prior, during their training...

Susan said...

If the rattle is not treated with medications, and the dying person is coughing frequently,(at least once a minute) can choking actually be the cause of death? this seems to be what I witnessed with my mother.

Pat Christian said...

When my father was dying in the hospital under hospice care, he began to experience a death rattle about 30 minutes before death. We raised the bed, he opened his eyes and looked at all of us there around him, closed his eyes and drifted away very peacefully. I was curious about the sounds he had made and found this post, which was very helpful and comforting to me.I think that raising the bed may have relieved the symptoms, and it also alerted us so we were fully with him as he took his last breathes.

Anonymous said...

I experienced it a family member for the 1st time last night. Very disturbing sounds. She was suctioned and given atropine. This post helps me to understand the process and that she most likely was not in pain and discomfort. Thank you.

bwk said...

I work in a very busy neuro-trauma ICU where we do our fail share of end of life care/ Comfort Measure Only/withdrawl of care. We are currently working on making our unit more aware of when this takes place & putting some nice memorials in place, such as "lighting" and electric candle or lantern. Do you have any other ideas? Thanks.