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.

Breaking My Anonymity

Ever since I started this blog, I have been writing under the pseudonym "Mia Adams." My reasoning for this was based on my own personal experience of coming across one of my health care providers on-line and my fears that she would somehow reference me (even indirectly) in her posts. Not wanting to create that same fear in my patients, I decided to use a pseudonym.

As part of that, I opened up a separate email account for this blog. However, as you may have noticed, I have not been posting as frequently as I once was. And as a result, I have also not been checking that email account very often either.

Unfortunately, I am technically unable to change my email address for this blog (as both addresses are gmail accounts which conflict with the google-based applications for blogger). But I will at least unveil the woman behind the curtain, so to speak.

My real name is Melaina and my real email account is Melaina RN at gmail dot com. So please send any correspondence to that account if you would like to receive a timely response.

I have given a lot of thought to this blog recently and am considering picking it back up again. Of course, I am thinking of potential new directions to take it in. With the advent and increased popularity of video posts, I may explore that avenue. Though for the time being, revealing my real name seems public enough, I think. :-)

But I welcome your input as well. I have received so many wonderful and supportive comments on this blog, even during my own silences. Thank you so much for the feedback. I would like this to continue to be a space that enriches the lives of my readers as well as continues to stimulate me to explore new subjects and areas, especially pertaining to issues such as quality of life, palliative care, bioethics, hospice and the end-of-life. Please send any suggestions for topics or any questions that I have left unanswered. I'm hoping with a little attention, I can bring this blog back to life.

Thank you so much for reading!

Sincerely,
Melaina

Last 24 Hours Illustration

Sorry for the long silence on this blog. I have been spending my time off-line drawing comics as a new creative outlet, which has taken up the time I used to spend writing this blog. Lately, I have been starting to draw illustrations pertaining to the end-of-life and I thought it would be appropriate to start posting these on this blog. Definitely a change of pace from this blog's former content.

The Great Cremation Ground

One of my colleagues just came back from a trip to India and told me about a place called Manikarnika Ghat, also known as "The Great Cremation Ground."

According to Hindu mythology, being burned here provides an instant gateway to liberation from the cycle of births and rebirths. Karmic bonds are suppose to be burnt along with the body, which is how one is liberated from needing to be rebirthed. It is said that the funeral fires at the Manikarnika ghat have been burning for thousands of years. A constant stream of corpses come to this ghat to be burnt, day and night. According to my colleague, most corpses do not get enough time to burn properly and are often unceremoniously dumped, half burnt into the sacred river.

I have never traveled to India, but if I do, this certainly seems like an interesting place to check out.

Estimating Time of Death

I am not in the practice of having to estimate time of death, as generally patients in the hospital are being watched routinely, and thus the time of death is already known. But I am on a list serv where someone posed a question that elicited this link. I thought the link was an interesting resource and might be useful to others, so I thought I'd post it here. This link is to a tool for estimating time of death, according to the Method of Henssge. It is based on temperature and puts into account various environmental factors including clothing. Check it out.

Your Truth: Dementia and Grief

I apologize, once again, for my on-going silence on this blog. I've received a number of emails from readers encouraging me to post again. I appreciate the dedicated interest in this blog from my readers.

I recently attended a fascinating lecture on dementia and grief. Inspired by this lecture, I am going to pose a hypothetical scenario for your consideration. As per my standard format, after the scenario, I am going to ask some questions and will later post my response to the scenario.

Mrs. Horton is an 86 year old with middle stage dementia. She is no longer able to recognize family members nor dress herself. She is able to walk, using a walker, and frequently gets lost in the hallways of her nursing home.

Mrs. Horton's 61 year old son recently died of heart attack. Prior to his death, her son had come to visit her in the nursing home at least three times every week. Mrs. Horton was informed repeatedly of her son's death, but she does not have the short-term memory to retain this information. She asks where her son is multiple times every day.

1. Do you repeatedly inform Mrs. Horton that her son died, even though this news is distressing to her? Would telling her the truth be retraumatizing her or banging her over the head with the news?

2. Understanding that disclosing this news can be distressing to both Mrs. Horton and to the bearer of this news, what are some different ways you might respond to her repeated request for her son?

Thank You, Blue H News!

blue-H-sign
Originally uploaded by miaadams.

I have been rather neglectful of this blog as of late. Despite my silence, I am delighted to report that Blue H News picked up one of my blog posts and published it in the January 2007 issue of their newspaper.

Thanks so much for the press, Blue H News!