Why Standard Drug Treatments for the “Death Rattle” Should Be Discontinued

The “death rattle,” or noisy breathing creating a disturbing sound at the end of life, is observed in many patients in the last hours of life. To treat the rattle, a type of anticholinergic drugs called antimuscarinics, which reduce secretions, is standardly given. ¹ However, antimuscarinics have not been shown to be effective at treating the rattle. Furthermore, there is no evidence that the rattle causes distress to the patient, who is nearly universally unconscious and unresponsive. Treatment is nevertheless standardly given out of a concern to relieve anxiety and distress in family members who hear the rattle.

A systematic review by Martine Lokker and colleagues found that there is little to no evidence for the efficacy of antimuscarinics in treating the death rattle. ² The review found that existing studies of these treatments either show no effect compared with no treatment, or small to moderate effect in some small studies of patients. This lack of evidence is disturbing because these drugs come with risks to the patient, including urinary retention, agitation, confusion, delirium, and even tachycardia. ³

The only evidence of antimuscarinic efficacy comes from a recent study of their use as a prophylactic. ⁴ A proponent of antimuscarinics could for this reason insist on using them in advance of the appearance of the rattle. However, this would still mean that treating the rattle after it has occurred is not empirically justified, and this is when they are most often used. ¹

There is also a more general problem with the use of antimuscarinic treatments for the rattle: they are intended to provide benefits only to nonpatients, at the cost of risks to the patient. Although palliative medicine considers the patient and family members to be the unit of care, it is still the patient who is primary and treating the rattle only benefits others, and at potential costs to the patient. Nonpatients may permissibly benefit from an intervention, but there is a significant moral problem when it is known that a drug treatment cannot benefit the patients it is administered to, can possibly harm them, and can only benefit others. A patient and family-centered care approach for this reason does not support standard antimuscarinic treatments for the rattle.

Standard drug treatments for the death rattle should be discontinued because (1) they are not sufficiently supported by evidence and (2) even if they are effective, they would constitute impermissible treatment of patients solely for the benefit of others. Heisler et al. recommend “advance education and reassurance of families” regarding the causes of the rattle and why it likely does not harm the unconscious dying patient. ³ They present anecdotal evidence that this is a promising method of reducing distress in others from the rattle. ³ Instead of antimuscarinics, occurrence of the rattle could be approached as an opportunity to start or continue a conversation with loved ones about goals and values surrounding end-of-life care.