Death Rattle 02/21/2010
 
Most of us have heard this term. It is the noisy rattling sound that a dying person makes that can be very disturbing to hear.

Death rattle happens when secretions gather in the throat because the person is too weak to swallow. The gurgling sound happens when air passes through the secretions upon exhale.  This doesn't necessarily mean the person is having trouble breathing.

There are things we can do to minimize this. There are standard medications to use that dry these secretions. Repositioning the person is very effective. Sometimes in repositioning, secretions will come out of the nose or pool in the mouth. Suctioning them at this point will provide comfort and relief for the family.
It is distressing often for the family to hear this. People fear the person is drowning or will choke to death. This is not so.

It is one of the final things that happens. Know that when you hear this, death is usually imminent, but this phenomenon can also happen days before death. It does not always mean within hours; just know that death is not far off.
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There is a phenomenon called terminal agitation, which may occur when a person is near the end of life.

It may look like this: picking in the air, taking off one's clothes no matter who is around, trying to get out of bed regardless of safety issues, wanting out of bed and then wanting to go back to bed within 5 minutes, among many other "fidgety" and "restless" behaviors. There may be yelling, moaning, crying and hallucinations. The person is not satisfied regardless of the family's attempt at soothing or providing what is requested.

This is agonizing for the family and this behavior has many possible causes and may take a long time to remedy. It can make otherwise reasonable family members angry and distraught. Know that if the person could change this she would. Nobody who is aware of herself and could do something about it would continue it.

With very difficult cases, strong medication is needed and families sometimes have much trouble with knowing their loved one will be sedated. Sedation vs. agitation. Think about what you would want.

I wrote a more in-depth article on the Quality of Life Care webste titled "Agitation vs. Sedation"


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When someone is dying a natural death, there is a breathing pattern that usually happens. It goes something like this: a deep breath or 2, then holding it, followed by a shallow breath or 2, and so on. It is an uneven pattern of inhales and exhales. It can be scary if you don't know it is coming.

Another thing that happens is as the person gets closer to death, the time between inhales widens. When breaths are towards 20-30 seconds apart, death may be happening very soon. I say "may" because there is always someone who may have this breathing pattern and live much longer. Overall, breaths will be getting more shallow and the time between inhales will space out.

There are exceptions to everything, but generally this is what you will see. Of course right now I want to tell you all the ways it could be different and how many ways breathing can look even with the above very general guidelines. The best thing to do is when you are going through this time, ask your hospice doctor or nurse about it and ask them to show you what you will be seeing. I do this with the people I care for. I show them some ways it can look and when it happens, they aren't as startled.

The pattern is called 'cheyne-stokes' respirations.

" ... Cheyne-Stokes respirations refer to a rhythmic change in respirations wherein breathing becomes shallower and shallower variably with a slowing in respiratory rate that culminates usually in complete cessation of breathing for several seconds to more than a minute. This is followed by progressively stronger respirations that become exaggerated and quite deep. This pattern is thought to result from abnormal brainstem responses to CO2 levels in the blood - initially undercompensating and then overcompensating. Cheyne-Stokes respirations can occur in other nonterminal disorders such as heart failure and stroke. It is interesting to note that patients who are able to speak generally say that no distress is associated with this breathing pattern. From this we may extrapolate to dying patients, who usually cannot speak with Cheyne-Stokes respirations, and presume that the syndrome is not disturbing to the patient. However, family members and clinicians may assume or project distress into this syndrome and thus often need to be coached. I usually explain that the pattern results from a breakdown in "cycling" between the lungs and the brain and that, as far as we know, it is not bothersome to the patient ... "            Palliative Care Perspectives-- James L. Hallenbeck, MD

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