How are terminal secretions managed in hospice care?

Physiology and Management of Terminal Secretions in Hospice Care

Physiological Mechanism

Terminal secretions, commonly called "death rattle," occur when dying patients lose their ability to clear saliva and mucus from the oropharynx and upper airways, creating noisy, gurgling respirations as secretions oscillate with breathing. 1, 2 This affects approximately 25% of imminently dying patients and results from progressive weakness of swallowing muscles and decreased consciousness, not from increased secretion production. 1

The noisy breathing arises from two distinct sources that require different management approaches:

• Bronchial secretions - These respond to anticholinergic medications and elimination of intravenous fluids 1
• Intrinsic lung pathology - This type usually resists pharmacologic therapy 1

Clinical Management Algorithm

First-Line Pharmacologic Intervention

Anticholinergic agents are the primary treatment for terminal secretions, with glycopyrrolate, scopolamine, atropine, and hyoscyamine all being acceptable options. 1, 3

Glycopyrrolate (0.2-0.4 mg IV or SC every 4 hours PRN) is often preferred because it does not cross the blood-brain barrier and is less likely to cause delirium compared to other anticholinergics. 1 However, it can still produce anticholinergic side effects. 1

Alternative anticholinergic options include:

• Scopolamine 0.4 mg SC every 4 hours PRN or 1.5 mg transdermal patches (1-6 patches every 3 days) 1 - Note that transdermal patches have a 12-hour onset and are inappropriate for imminently dying patients; subcutaneous injection should be given when applying the patch or if secretion control is inadequate 1
• Atropine 1% ophthalmic solution 1-2 drops sublingually every 4 hours PRN 1, 2 - This sublingual route obviates the need for subcutaneous infusions 2
• Hyoscyamine 1

Evidence Quality and Drug Selection

The evidence comparing these agents shows conflicting results. 4, 5 A 2023 network meta-analysis found no statistically significant difference between any anticholinergic and placebo for death rattle treatment, though hyoscine butyl bromide had the highest ranking (SUCRA 71.3%) and showed potential for prophylaxis. 6 One comparative study found glycopyrrolate superior to hyoscine hydrobromide, with all glycopyrrolate patients showing some response versus 22% of hyoscine patients having no response (p < 0.01). 5

Non-Pharmacologic Interventions

Discontinue intravenous fluids, as fluid overload contributes to respiratory congestion and gurgling. 1 This intervention should occur before ventilator withdrawal in ICU settings. 1

Position the patient on their side or semi-prone to facilitate drainage of secretions. (General medical knowledge)

Family Education and Support

Families must be counseled in advance that noisy breathing does not indicate patient suffering or discomfort. 1 This anticipatory guidance is critical because witnessing the death rattle causes significant family distress even when patients are not suffering. 1

Distinguish "death rattle" from "agonal breathing" (slow, irregular, noisy breathing mimicking grunting or gasping that occurs minutes before death) - both are part of the normal dying process and do not require increased opioid dosing by themselves. 1

Common Pitfalls to Avoid

• Do not use transdermal scopolamine patches for imminently dying patients - The 12-hour onset makes them inappropriate; use subcutaneous administration instead 1
• Do not increase opioid doses in response to death rattle or agonal breathing alone - These sounds do not indicate respiratory distress requiring opioids 1
• Do not assume all noisy breathing is treatable - Secretions from intrinsic lung pathology typically resist therapy 1
• Do not overlook the need for family support - Managing family distress is as important as treating the patient, as some families experience significant distress witnessing noisy breathing 1

Monitoring Parameters

For imminently dying patients, monitor only comfort parameters, not vital signs. 1 Respiratory rate should be assessed primarily to ensure absence of respiratory distress and tachypnea, not as a reason to decrease medications. 1 A gradual deterioration of respiration is expected as patients near death. 1