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Communication vignettes: ‘Help her nurse, she’s drowning!’
  1. Helen Scott, Editor and
  2. Vicky Robinson, Consultant Editor
  1. Helen Scott is Editor, End of Life Care, and Vicky Robinson is Consultant Editor, End of Life Care, and Consultant Nurse in Palliative Care, Guy’s and St Thomas’ NHS Foundation Trust, London

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Death rattle is the term commonly used to describe noisy, rattling breathing that occurs at the very end of life. It usually affects terminal patients who are unconscious or too weak to expectorate. Its cause is unknown. It is thought to be the result of the oscillatory movements of secretions/saliva accumulating in the patient’s upper airways (Twycross and Wilcock, 2007; Wildiers et al, 2009). However, there is no strong evidence regarding the pathophysiology of death rattle and further research into the mechanisms resulting in the noisy breathing is required (Wee and Hillier, 2009). The death rattle is accepted as a clinical indicator that death may soon occur, i.e. in hours or days (Wildiers et al, 2009). Full discussion of the management of death rattle is outside the remit of this vignette. The topic will be covered in a future issue of the journal. Interested readers should refer to the Palliative Care Formulary, which sets out best practice guidelines (Twycross and Wilcock, 2007).

Death rattle is one of the symptoms in palliative care for which no strong evidence base exists relating to treatment (Wee and Hillier, 2009). Traditional treatment has been the administration of antimuscarinic drugs (the aim being to reduce the amount of secretions accumulating), positioning the patient in a semiprone position to encourage drainage (or, if the secretions are the result of pulmonary oedema or gastric reflux, positioning in an upright or semirecumbent position) and suctioning (if the patient is unconscious) (Twycross and Wilcock, 2007; Wee and Hillier, 2009). However, these interventions have varying levels of success. A recent Cochrane systematic review confirmed the lack of high-quality evidence for such practices (Wee and Hillier, 2009). For example, there is currently no strong evidence that one antimuscarinic drug is more effective than another. Until definitive research …

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