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


Journal of Hospice and Palliative Nursing. 2014;16(8) 

In This Article

Abstract and Introduction


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 non-pharmacologic, particularly communication-based, interventions for death rattle.


Case Study

Mr E. was 66 years old with advanced gastric lymphoma and was dying at home, being cared for by his family. He was somnolent, but his respirations were unlabored, and lung sounds were clear. The hospice nurse educated his family on the signs and symptoms of active dying and the use of comfort medications, including 1% atropine eye drops to be given sublingually as needed for respiratory secretions.