by Rebecca Gagne-Henderson PhD APRN ACHPN
What is the Death Rattle?
In the early 2000’s I noted many hospice physicians began to refer to the death rattle as hypersecretions. The secretions may at some point become copious, but the term “hypersecretions” indicates a disorder which produces an excessive amount of secretions. In addition to hypersecretions, other terms have been suggested such as “terminal congestion” and “retained secretions” to diverge from death rattle which some find distasteful (1). These terms are inaccurate and pathologize a natural process. It is fortunate, that for the most part, this terminology has not taken hold among palliative types.
The death rattle, which is the accurate and culturally appropriate term, occurs at the end of life and is a sign of impending death (2). In my humble research for this post, the earliest mention I found of this term was by Hippocrates (3). This confirms the origin of the term to be based in medicine and is ancient (not antiquated), but it is referred to as a colloquialism in more modern writings. In either case, this is evidence that it is an appropriate use of the term.
In a systematic literature review, the prevalence of this phenomenon is reported at 23-96% (2). This indicates that we really don’t know the correct number. The death rattle is the accumulation of secretions as they pool in the trachea. The term is used to describe the sound once the secretions reach the point where they become audible as air flows through the accumulated secretions.
A Symptom or a Sign?
One thing to understand about the death rattle is that it is not distressing to the dying person (4). If one were not dying this would cause distress. During the dying process, our autonomic reflexes fail due to decreased levels of oxygen and the progressing cessation of brain activity. We lose our gag, cough, and swallow reflexes, which if intact would be very uncomfortable. We would gag, and cough in attempts to clear these secretions. It is the triggering of these reflexes which would cause discomfort. The loss of these reflexes is a natural process as our autonomic system fails during the dying process. The accumulation of continued secretions is the short ongoing secretion of acetylcholine which continues to trigger muscarinic release of saliva and bronchial secretion (2). The secretory mechanisms will cease with the brain’s continued cessation through the dying process.
There are some conditions which do cause “hypersecretions”. Such conditions could be lung cancer, fulminant pneumonia (a rapid and severe pneumonia infection), and tracheal irritation from intubation and extubation. These are known as pseudo-death rattle (1). I would be remiss to not mention that when some people are extubated stridor may occur. This is a constricting of the trachea causing breathing to become difficult and noisy. This can be distressing for the patient at times and to those witnessing the condition, but it is not the death rattle.
What is distressing about the Death Rattle?
It is important to know that when clinicians treat the death rattle, they are not treating the patient, rather they are alleviating the discomfort of bystanders. Anything which indicates the cessation of life is abhorrent to living beings. The death rattle is one of those things. This concept complies with the theory of evolution. As organisms, we have an innate survival instinct which repels us from those things not conducive to life. Death is seen as a real threat for those with a survival instinct. Babies cry when they are cold, hungry or have discomfort to alert the mother of their needs before death takes its grip. This occurs on the day of birth during the developmental stage of Trust vs. Mistrust as described by Erikson (5). A certain amount of death anxiety is part of our survival instinct. There are three types of death anxieties. These are Predator, Predatory and Existential types (6). The Predator and Predatory types of death anxiety are healthy protective adaptions to our environment to assure the survival and the opportunity for reproduction. Existential death anxiety is what separates us from other mammals. What makes us different in our adaptation is the power of language and creativity. Of all mammals, we can define our dangers and even creatively engage in the storytelling of thelived experiences of war, rampage, and freak accidents. Our ability to know a creator and predict our deaths enhances our understanding of our own demise and leads to less healthful coping, known as existential death anxiety, but I digress.
To Treat or Not to Treat…?
Successful treatment modalities for this natural condition are limited and the evidence is varied. There is no standard regarding first-line medication for use in the death rattle (1, 4, 7-9). When three anticholinergic medications were studied in a dying population, fewer than half of the sample responded at all to the intervention (7). This was the case for all three arms of the study. The question is “why treat this condition at all with pharmaceuticals”? A non-pharmacological remedy is repositioning to move the secretions away from the trachea. If secretions move to the oral cavity they may be suctioned (ORAL suctioning) or dried with a cloth.
Treating a natural and harmless condition without a medical purpose brings up ethical questions. Should we give someone medication to assuage another’s discomfort? Treating the death rattle has its drawbacks. The anticholinergics used add cost to the treatment of the dying patient. It also is a source of xerostomia (7). This is the medical term for a very dry mouth. Xerostomia has been described as the second most distressing condition, after pain, in the dying patient. In addition, these drugs may cause urinary retention and a distended bladder. This distressing and painful condition causes agitation and may require an invasive straight catheterization on the deathbed. This is not conducive to a peaceful death. The other consideration would be the families’ responses when their healthcare provider has offered an intervention which fails to provide the expected results. This may cause a loss of trust in the provider and be even more distressing than if the death rattle had been explained simply as a natural occurrence which does not inflict pain nor distress.
The persistent need clinicians have to do something, anything, to solve a non-existent problem is further evidence of the over-medicalization of death that is occurring in palliative care. I liken dying to natural childbirth. The body knows what to do. Modern medical overtreatment sometimes complicates this natural and potentially beautiful process. We need to stand back and let nature take its course, IMHO.
1. Fielding F, Long CO. The death rattle dilemma. Journal of Hospice & Palliative Nursing. 2014;16(8):466-71.
2. Twomey S, Dowling M. Management of death rattle at end of life. British Journal of Nursing. 2013;22(2):81-5.
3. Couch JH. The tendon of Achilles. Canadian Medical Association Journal. 1936;34(6):688.
4. Campbell ML, Yarandi HN. Death rattle is not associated with patient respiratory distress: is pharmacologic treatment indicated? Journal of palliative medicine. 2013;16(10):1255-9.
5. Erikson EH, Erikson JM. The life cycle completed: Extended version. New York, NY: W.W. Norton & Co.; 1998.
6. Langs R, Giovacchini PL. Death anxiety and clinical practice: Routledge; 2018.
7. Bennett M, Lucas V, Brennan M, Hughes A, O’Donnell V, Wee B. Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care. Palliative Medicine. 2002;16(5):369-74.
8. Wildiers H, Dhaenekint C, Demeulenaere P, Clement PM, Desmet M, Van Nuffelen R, et al. Atropine, hyoscine butylbromide, or scopolamine are equally effective for the treatment of death rattle in terminal care. Journal of pain and symptom management. 2009;38(1):124-33.
9. Campbell ML. Assuaging listener distress from patient death rattle. Ann Palliat Med. 2019;8(S1):S58-S60.