Death rattle in the dying phase: is prophylactic treatment effective?

Death rattle occurs in about half of the patients in the dying phase. Relatives often experience this as disturbing. Anticholinergics are recommended to treat death rattle, although there is no evidence for the effect of these drugs. Whereas anticholinergics do not affect existing mucus, it may be more effective when given preventively. We designed a study to test this hypothesis in patients admitted to a hospice.

The study will be conducted in four hospices in the Southwest region of the Netherlands.

Participating centers:

- Laurens Cadenza, Oosterhagen 239, 3078 CL, Rotterdam

- Hospice Calando, Vivaldilaan 2 ¡§C 4, 3247 EE Dirksland

- Hospice de Regenboog, Oudedijk 11, 3062 AB Rotterdam

- Stichting Curamus, hospice de Meander, Truffinoweg 2, 4561 NT Hulst

About half of the patients in the dying phase experience death rattle: noisy breathing caused by the presence of mucus in the upper respiratory tract. Patients may be afraid of the occurrence of death rattle. Memories of loved ones with this phenomena are often associated with ¡¡ãchoking¡¡À. For the relatives its rattling noise can be unpleasant and disturbing. They may fear that their loved one suffers from it.
Awareness and posture changes in bed are the recommended actions. If the rattle is nevertheless perceived as burdensome, drugs (anticholinergics) can be considered. However, there is no evidence for the effect of these drugs. Whereas anticholinergics do not affect existing mucus, it may be more effective when given preventively. We designed a study to test this hypothesis in patients admitted to a hospice.

From the start of the dying phase every four hours observations are made by the nursing staff. They report these observations in the Care Pathway for the Dying, which will be started at the moment that the dying phase is recognized. The observations will end at death of when the primary endpoint is met. The care pathway is adapted for clinical research and includes extra observations by and questions to the nursing team.

After three months a questionnaire will be sent to the relatives.

At the recognition of the dying phase the patient will start with scopolaminebutyl 20 mg(=1 ml) or placebo (=1 ml NaCl 0.9%) four times a day subcutaneously. Treatment will be continued until death or until the occurrence of death rattle with a severity of grade ¡Ý 2 according to the scale of Back at 2 consecutive measurements with an interval of 4 hours. Standard care as provided in the hospices will be continued.