APA CONSULTANTS ACADEMY REPORT
The Death Rattle and the Pharmacist
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s a person draws closer to the time of death, especially with the hospice patient, we as care givers become faced with palliative therapies to maintain the person's comfort and dignity. The pharmacist can play an important role with symptom management and can assist in the quality of life for that patient. Anthony Hughes, P.D. President
Issues that can easily present themselves are constipation, nausea and vomiting, pain, and the Death Rattle. Some may say what is the Death Rattle? The Death Rattle is sounds often produced by someone who is near death as a result of fluids such as saliva and bronchial secretions accumulating in the throat and upper chest. It occurs in about 92% of patients. The mental changes happening in the dying process causes the patient to lose the capacity to clear these upper respiratory secretions. Somewhere between 11 to 28 hours are common from the onset of the Death Rattle and death. It has been suggested that symptom management started earlier with lower rattle intensity improved effectiveness over time. One of the most interesting things (blessing) that happens is that the patient normally does not express to others that these sounds or rattles are distressing. These sounds do produce anxiety and distress for the family members and the care givers. During these final hours things such as frequent turns, repositioning and a reduction of parenteral fluids are not harmful and may be the appropriated course. There are a couple of studies that found levels of hydration did not change the prevalence of death rattle. Providing education about the Death Rattle could be as effective as the repositioning and medications. Some consider suction but unless secretions are visible in the mouth, suction should be avoided. A review of the available literature in the management of the Death Rattle we quickly see that the studies are very limited and produce the need for a well planned and executed study. After repositioning and turns what options do we have? The answer is the anticholinergic medications atropine, glycopyrrolate, hyoscyamine and scopolamine. No one product is superior to the rest. It may come down to ease of administration and product availability. These situations should follow the palliative care guidelines to start low and go slow.
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An interesting bit of the history with atropine is that it was used by Cleopatra, Renaissance women, and in Paris at the turn of the 19th century to dilate their eyes in the hopes they would appear more alluring. Let’s hope they could see their prospective candidates. Atropine is the easiest for the caregiver to use. Using the ophthalmic 1% drop with 2 drops under the tongue titrated up every 4-8 hours produces about 1mg of
Consultant Clinical Pearl What common class of medications has an increased adverse effect with GI issues and sleep disturbance? Answer: SSRIs
atropine. It is thought that glycopyrrolate may be better in patients who are more alert and bothered by the rattles. Glycopyrrolate is usually doses at 1mg orally or 0.10.2mg SubQ/IV every 4-8 hours prn. Hyoscyamine can also be administered sublingual at 0.125 to 0.5mg every 4 hours as needed. A tip for the caregiver is to provide a few drops of water with the sublingual tablet will greatly assist the dissolving of the tablet. Scopolamine crossed the blood-brain barrier, causing more sedation and possible delirium and agitation in higher doses. It is suggested to apply 1-2 patches every 72 hours as needed. However, slow onset may reduce its effectiveness. No one medication stands out as superior but comes down to the situation at hand and what is best at that time. Who knows? You may be one that can provide the education for all involved to ensure a quality of life at the time of death. §
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