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The Death Rattle Dilemma

Fielding, Flannery MS, NP, ACHPN; Long, Carol O. PhD, RN, FPCN, FAAN

Journal of Hospice & Palliative Nursing: December 2014 - Volume 16 - Issue 8 - p 466–471
doi: 10.1097/NJH.0000000000000090
Symptom Management Series

Death rattle, defined as the noise created by the flow of air through secretions in the upper respiratory tract, is a well-known phenomenon associated with the dying process. The use of anticholinergics is standard practice in hospice and palliative care, yet despite a growing number of quality clinical trials, there is still no compelling scientific evidence that our interventions for death rattle are effective. Studies to date have focused on antisecretory agents, primarily anticholinergics, with mixed results and variable interpretations. Recent placebo-controlled data suggest that death rattle may tend to diminish over time without medication. Objective measurements of patient distress indicate that dying patients experience very low levels of respiratory distress with or without death rattle. While treatment is often initiated based on the perceived distress of family members, emerging qualitative data suggest that death rattle is not always distressing to family and caregivers. Our current approach to death rattle presents a clinical and ethical dilemma; a better understanding of the range of responses and interpretations will allow nurses to frame the discussion of death rattle more effectively and help to guide care. More research is needed into nonpharmacologic, particularly communication-based, interventions for death rattle.

Flannery Fielding, MS, NP, ACHPN, is nurse practitioner, Section of Palliative Medicine and Supportive Oncology, Department of Solid Tumor Oncology, Cleveland Clinic Taussig Cancer Institute; and the Harry R. Horvitz Center for Palliative Medicine (a World Health Organization Demonstration Project in Palliative Medicine and an ESMO-Designated Center of Integrated Oncology and Palliative Care), Cleveland Clinic, Ohio.

Carol O. Long, PhD, RN, FPCN, FAAN, is principal, Capstone Healthcare, Phoenix, Arizona.

Address correspondence to Flannery Fielding, MS, NP, ACHPN, M76, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195 (

The authors have no conflicts of interest to disclose.

© 2014 by The Hospice and Palliative Nurses Association.