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What is the death rattle?

Background. Death rattle is a common symptom in the dying phase which is caused by an accumulation of secretions in the upper airway [1]. This accumulation of fluid (mucus) cannot be easily coughed up or swallowed by the patient, often as a result of a diminished consciousness.

bmcpsychology.biomedcentral.com - Understanding relatives' experience of death rattle - BMC Psychology

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We found that death rattle can be a stressful symptom for relatives, which confirms findings from previous studies [4,5,6]. We found no positive experiences of the sound of death rattle, in contrast to others [4]. The experience of relatives who valued death rattle as burdensome is affected by more factors than the sound alone. Previous experiences with death rattle, insecurity about the burden for the patient and a longer duration of the death rattle seem to negatively influence relatives’ experiences. Relatives who did not value death rattle as burdensome did not describe these experiences. All participants felt that informing them about death rattle had a limited impact on their experience of the symptom. Symptoms such as pain, dyspnea and delirium seem to reduce the impact of the experience of death rattle.

Relationship to prior research

Death rattle is a symptom that has been suggested to be more bothersome for relatives than for the patient. It is an experience in which all senses are stimulated: relatives can hear the rattling, they can see the mucus drip and they sometimes can smell this mucus. The sound and look may result in a feeling of distance in a period in which intimacy is important. Campbell (2018) suggested that ‘normalization’ of the sound of death rattle is better than medical treatment to assuage family members’ and clinicians’ distress [12]. Wee and Hillier [5] and Shimizu [4] found that frequent explanations and understanding relatives’ interpretations of the sound is important to alleviate the burden of death rattle. However, our results indicate that the experience of death rattle may not be influenced by information given to the relatives. Normalizing the sound does not seem to sufficiently alleviate the experience of relatives in all cases either. In this study, we see that other symptoms sometimes have more impact on relatives than death rattle.

Strengths and limitations

A strength of this study is that it is the first attempt to identify factors which influence the experience of death rattle in addition to the sound alone. By interviewing all relatives at home, we created an atmosphere in which they felt comfortable and free to share their experiences. The impact of death rattle for loved ones became very clear. Their vividly described experiences suggest that, although time had passed, the experience of death rattle was still very much alive. Our study has some limitations. First, the response rate was low, which may have been caused by practical reasons as a rehousing of the relatives, mail getting lost or ignorance of relatives for an information letter. Second, self-selection may have been a problem. Relatives may not have wanted to participate and share their experiences, because they experienced a stressful dying process with many burdening symptoms and suffering.

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And finally, the timing of the interviews varied from 3 to 12 months after death. The months between death and the interview can alter bereaved relatives’ memories and feelings about the dying process [17, 18].

Implications for practice and future research

Not all relatives valued death rattle as burdensome, but for those who did, the experiences were influenced by more than just the noise. Further research on how to manage death rattle is needed, because of the burden for some relatives and uncertainty about the burden for the patient. Drug treatment could be considered to manage death rattle. Previous research has suggested that anticholinergics can be used to diminish death rattle, but variable effects have been shown [9,10,11]. In these studies the medication was started when death rattle arose. It has been suggested that these drugs could be more effective when they are administered prophylactically, that is, before death rattle occurs [11, 19]. One recent, non-placebo controlled study found that prophylactic anticholinergics for death rattle may be effective [19]. A placebo-controlled RCT on prophylactic use of scopolaminebutyl is currently being conducted [20]. At this moment, communication and information about death rattle is what health care professionals can offer the relatives. The phenomenon of death rattle should be addressed by health care professionals by acknowledgement of former experience of patients and relatives, and by providing accurate information and communication. Information should consist of a clear explanation of the symptom and the probably limited degree to which patients suffer from it, confirmation that the patient is in the dying phase, and an explanation of the measures that can be taken to diminish the sound. This information must be repeated regularly (if necessary more than daily).

bmcpsychology.biomedcentral.com - Understanding relatives' experience of death rattle - BMC Psychology

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