Abstract
Dear Editor:
The management of death rattle continues to be an area of controversy. The letter by Mr. Sarbey suggests that medications should not be used for death rattle management because medication targets distress of the family, not the patient. 1 Although Mr. Sarbey states that the evidence does not support the efficacy of anticholinergic medications in managing secretions, recent evidence demonstrates that scopolamine butylbromide when given prophylactically does reduce the occurrence of death rattle. 2 Although Mr. Sarbey suggests that treatment for death rattle is of no benefit to the patient, I am less certain. In their editorial, Lowe and Hanson encouraged humility before we, as providers, assume how distressing this symptom may be for the patient. 3 They also point out that the unit of care is the patient and family, and potentially disturbing symptoms left uncontrolled may have a profound and negative impact on the family.
As providers, we often explain to families that hearing is preserved until the end of life. We speak to our patients before and while we examine them. We encourage the families to speak to them as well. But then we explain that the patient does not hear the death rattle, much like people do not hear their own snoring. It is understandable then why some families might wonder how the patient can hear their voices but not a loud death rattle that can be heard in the hallway.
A colleague of mine explained that one of the most disturbing things she has experienced is the pooling of secretions in the back of her throat while sitting in the dental chair awaiting the hygienist to suction. I agreed I find that unpleasant as well and it made me wonder if our patients experience distress as secretions pool in their pharynx or in their airway.
Although routine treatment to prevent the death rattle in dying patient may not be standard practice, the suggestion that we avoid treatment of the death rattle goes too far. When the death rattle cannot be managed with positioning, many clinicians will intervene with medication. When a family tells us that they are afraid of this disturbing symptom or have traumatic memories of past deaths where there was a loud death rattle, we may choose to intervene early with medication. This approach is patient and family centered and will hopefully limit suffering and improve care.