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van Esch HJ, Campbell ML, Mori M, Yamaguchi T. Should (Prophylactic) Medications Be Used for the Management of Death Rattle? J Pain Symptom Manage 2023; 66:e513-e517. [PMID: 37343900 DOI: 10.1016/j.jpainsymman.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 06/23/2023]
Abstract
Death rattle is a common symptom in the dying phase and has impact on relatives and health care providers. One controversial topic regarding the management of death rattle in the dying phase is whether the symptom should be treated. In this "Controversies in Palliative Care" article, three expert clinicians independently answer this question. Specifically, each group provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. The three experts have different opinions on the assessment of death rattle. This seems to depend on the unknown burden of death rattle on the patient. Explanation of the symptom and reassurance could be sufficient. But considering the known burden on some of the relatives, there might be good reasons to use medication to relieve this symptom. Whether this treatment should be performed preventively or only when death rattle develops remains an matter of debate. Further scientific, clinical, and societal debate on the concept of a "good death" for relatives, the meaning of the symptom death rattle, and the impact of medication is needed.
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Affiliation(s)
- Harriette Johanna van Esch
- Department of Medical Oncology and Department of Public health (H.J.E.), Erasmus Medical Center Cancer Institute, Rotterdam, Rotterdam, The Netherlands.
| | | | - Masanori Mori
- Department of Palliative and Supportive Care (M.M.), Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Takayashi Yamaguchi
- Department of Palliative Medicine (T.Y.), Kobe University Graduate School of Medicine, Kobe, Japan
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Taburee W, Dhippayom T, Nagaviroj K, Dilokthornsakul P. Effects of Anticholinergics on Death Rattle: A Systematic Review and Network Meta-Analysis. J Palliat Med 2023; 26:431-440. [PMID: 36194053 DOI: 10.1089/jpm.2022.0386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Anticholinergics have been used to treat death rattle (DR) in dying patients with palliative care. However, the effect of anticholinergics is still controversial. No quantitative summary of their effects is reported. Objective: This study aimed to systematically review and quantitatively synthesize the effect of anticholinergics on DR treatment and prophylaxis. Design: A systematic search was performed in the electronic databases (PubMed, Embase®, and Cumulative Index to Nursing and Allied Health Literature [CINAHL]) from inception to October 2021. Studies conducted to determine the effect of anticholinergics compared with other anticholinergics or placebo on noise reduction score in dying patients were included. A network meta-analysis was performed for DR treatment. The effect of anticholinergics at four hours was assessed. A pairwise meta-analysis was performed for DR prophylaxis. Results: A total of nine studies were included with 1103 patients. Six studies were randomized controlled trials, and three studies were cohort studies. Seven studies were conducted for DR treatment, while two studies were conducted for DR prophylaxis. For DR treatment, no statistically significant difference was observed between each anticholinergic (hyoscine hydrobromide, hyoscine butyl bromide, atropine, and glycopyrrolate) and placebo and among any anticholinergics. However, the surface under cumulative ranking curve indicated that hyoscine butyl bromide had the highest surface under the cumulative ranking curve (SUCRA) with 71.3%. For DR prophylaxis, the relative risk of DR occurrence for hyoscine butyl bromide was 0.23 (0.04, 1.18; I2 = 84.5%) compared with no treatment. Conclusion: This study showed no strong evidence of the regular use of anticholinergics for DR treatment. In addition, hyoscine butyl bromide appears to have a high potential for DR prophylaxis.
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Affiliation(s)
- Watcharaporn Taburee
- Department of Family Medicine, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Teerapon Dhippayom
- The Research Unit of Evidence Synthesis (TRUES), Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Kittiphon Nagaviroj
- Department of Family Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Piyameth Dilokthornsakul
- Center for Medical and Health Technology Assessment (CM-HTA), Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
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Yamaguchi T, Mori M, Maeda I, Matsunuma R, Tanaka-Yagi Y, Nishi T, Kizawa Y, Tsuneto S, Shima Y, Masukawa K, Miyashita M. The impact of death rattle on bereaved families: not the sound itself, but the resonance with their feelings. Jpn J Clin Oncol 2022; 52:774-778. [PMID: 35446952 DOI: 10.1093/jjco/hyac055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND This study aimed to explore (i) the consistency between physician-rated and bereaved family-perceived intensity of death rattle, (ii) the relationship between intensity of death rattle and the bereaved family's distress and (iii) the bereaved family's experience and feelings related to suctioning for death rattle. METHODS We used matched data for deceased patients from a prospective cohort study of cancer patients admitted to a palliative care unit, and their bereaved families from a nationwide questionnaire survey in Japan. The intensity of death rattle using Back's score was evaluated prospectively by physicians and retrospectively by bereaved families. RESULTS In total, 1122 bereaved families answered (response rate: 66.7%). Of these, 297 reported the development of death rattle. The maximum intensity of death rattle evaluated by physicians and perceived by bereaved families was poorly correlated (Spearman correlation coefficient 0.188, P = 0.082). The optimal cut-off point of Back's score for detecting high-level distress was 1/2, with a low accuracy of prediction (area under the curve 0.62). More than 70% of bereaved families indicated suctioning reduced the intensity of death rattle, made patients comfortable and themselves relieved, whereas a similar proportion felt patients were in distress during suctioning. Families who felt suctioning was gently performed and discussed well whether to do suctioning with health care providers felt less needs for improvement. CONCLUSIONS Bereaved family-perceived intensity of death rattle did not correlate to physician-evaluated intensity, and the intensity of death rattle itself seemed to poorly correlate to family distress. Gently performed suctioning based on sufficient discussion with families can help reduce family-perceived patient discomfort.
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Affiliation(s)
- Takashi Yamaguchi
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.,Department of Palliative Care, Konan Medical Center, Kobe, Japan
| | - Masanori Mori
- Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Isseki Maeda
- Department of Palliative Care, Senri Chuo Hospital, Suita, Japan
| | - Ryo Matsunuma
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.,Department of Palliative Care, Konan Medical Center, Kobe, Japan
| | - Yukako Tanaka-Yagi
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.,Department of Palliative Care, Konan Medical Center, Kobe, Japan
| | - Tomohiro Nishi
- Department of Palliative Care, Kawasaki Municipal Ida Hospital, Kawasaki, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Satoru Tsuneto
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasuo Shima
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Kento Masukawa
- Division of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Mitsunori Miyashita
- Division of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
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Yokomichi N, Morita T, Yamaguchi T. Hydration Volume Is Associated with Development of Death Rattle in Patients with Abdominal Cancer. J Palliat Med 2021; 25:130-134. [PMID: 34665043 DOI: 10.1089/jpm.2021.0297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Death rattle occurs frequently in dying patients with malignancies. The association the between hydration volume and death rattle development is controversial. Design and Setting: A secondary analysis using data from two multicenter prospective observational studies, including a total of 471 consecutive advanced cancer patients. Of these, we analyzed patients with abdominal malignancies. Measurements: The association of an artificial hydration volume one week before death with the development of death rattle 48 hours before death was evaluated with the adjustment of potential confounders using the propensity score-weighting method. Results: We analyzed 300 patients. The prevalence of death rattle was significantly higher in those receiving artificial hydration >500 mL/day than those receiving ≤500 mL/day (23.1% vs. 13.6%, respectively; adjusted odds ratio: 2.56; 95% confidence interval: 1.37-4.80; p = 0.0036). Conclusion: The hydration volume might be associated with death rattle development in patients with abdominal malignancies. Volume reduction may alleviate or prevent death rattle.
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Affiliation(s)
- Naosuke Yokomichi
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Palliative Care Team, and Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Takashi Yamaguchi
- Division of Palliative Care, Konan Medical Center, Kobe, Japan.,Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Matsunuma R, Suzuki K, Matsuda Y, Mori M, Watanabe H, Yamaguchi T. Palliative care physicians' perspectives of management for terminally ill cancer patients with death rattle: a nationwide survey. Jpn J Clin Oncol 2020; 50:830-833. [PMID: 32419027 DOI: 10.1093/jjco/hyaa044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/14/2020] [Accepted: 12/12/2019] [Indexed: 11/14/2022] Open
Abstract
Death rattle occurs during the last days of life, and relatives of those afflicted frequently report that it is very distressful. However, there is no effective treatment for it. The purpose of this study was to investigate the perceptions of Japanese palliative care physicians in clinical practice in Japan. We conducted a nationwide survey of 268 physicians via an anonymous, self-report questionnaire. We assessed pharmacological and non-pharmacological management and anticholinergic agent choice. One hundred eighty-nine physicians (70.5%) returned the questionnaires. Fifty-five participants (29.1%) treating patients with Type-1 (real death rattle) and 36 participants (19%) treating patients with Type-2 (pseudo-death rattle) death rattle reported that they would frequently administer an anticholinergic agent. One-fourth would administer scopolamine butylbromide or scopolamine hydrobromide. In conclusion, more Japanese palliative care physicians thought that anticholinergic agents might be effective for treating Type-1 death rattle rather than Type-2. Further clinical trials of these agents are needed.
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Affiliation(s)
- Ryo Matsunuma
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer, and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
| | - Takashi Yamaguchi
- Division of Palliative Care, Department of Medicine, Konan Hospital, Kobe, Japan
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Hindmarsh J, Everett P, Hindmarsh S, Lee M, Pickard J. Glycopyrrolate and the Management of " Death Rattle" in Patients with Myasthenia Gravis. J Palliat Med 2020; 23:1408-1410. [PMID: 31976808 DOI: 10.1089/jpm.2019.0598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Death rattle commonly occurs at the end of life and is typically managed with anticholinergic agents. Myasthenia gravis is an autoimmune disorder characterized by fatigability of skeletal muscle, resulting from autoimmune destruction of acetylcholine receptors at the motor endplate. The condition is treated with acetylcholinesterase inhibitors, which potentiate the action of acetylcholine. Agents that antagonize acetylcholine activity (e.g., anticholinergic agents, such as glycopyrrolate) can, therefore, exacerbate myasthenia gravis. We discuss the case of a patient dying with myasthenia gravis that developed problematic "death rattle," and the successful use of glycopyrrolate in treating this symptom.
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Affiliation(s)
- Jonathan Hindmarsh
- Inpatient Unit, Specialist Centre for Palliative Care, St. Benedict's Hospice, Sunderland, United Kingdom.,Department of Pharmacy, Sunderland Royal Hospital, Sunderland, United Kingdom
| | - Paul Everett
- Department of Pharmacy, Sunderland Royal Hospital, Sunderland, United Kingdom
| | - Sharlene Hindmarsh
- Department of Pharmacy, Sunderland Royal Hospital, Sunderland, United Kingdom
| | - Mark Lee
- Inpatient Unit, Specialist Centre for Palliative Care, St. Benedict's Hospice, Sunderland, United Kingdom
| | - Jonathan Pickard
- Inpatient Unit, Specialist Centre for Palliative Care, St. Benedict's Hospice, Sunderland, United Kingdom
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Mercadante S, Marinangeli F, Masedu F, Valenti M, Russo D, Ursini L, Massici A, Aielli F. Hyoscine Butylbromide for the Management of Death Rattle: Sooner Rather Than Later. J Pain Symptom Manage 2018; 56:902-907. [PMID: 30172864 DOI: 10.1016/j.jpainsymman.2018.08.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/22/2018] [Accepted: 08/22/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT Death rattle (DR) is a dramatic sign in the dying patient. Existing studies with anticholinergic agents are controversial, as this class of drugs has been commonly administered without considering the rationale of the mechanism of action. A meaningful use of these drugs may provide a better outcome. OBJECTIVES The aim of this study was to assess the efficacy of hyoscine butylbromide (HB), given prophylactically in comparison with HB administered once DR occurs. METHODS Dying patients having a score of ≥3 in the Richmond Agitation-Sedation Scale-palliative version were included in the study. HB (60 mg/day) was given when DR occurred (Group 1) or as pre-emptive treatment (Group 2). The onset of DR (death rattle free time) and intensity of DR were recorded at intervals until death. RESULTS Eighty-one and 51 patients were randomized to Group 1 and 2, respectively. Patients in Group 2 survived longer than those in Group 1 (P < 0.05). DR occurred in 49 (60.5%) and three patients (5.9%) in Group 1 and 2, respectively (P = 0.001). A significant difference in the number of patients reporting DR was found at intervals examined (30 minutes, one hour, and then every six hours until death [P = 0.001]). In Group 1 and 2, DR free time was 20.4 (20.5) and 27.3 hours (25.2), respectively (P = 0.001). In Group 1, the treatment was considered effective in 10 patients (20.4%) only, after a mean of 14.4 hours (SD 8.57). CONCLUSION The prophylactic use of HB is an efficient method to prevent DR, whereas the late administration produces a limited response, confirming data from traditional studies performed with anticholinergics. This could be considered a new paradigm to manage a difficult and dramatic sign, such as DR.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Palermo, Sicily, Italy.
| | - Franco Marinangeli
- Department of Life Health and Environmental Sciences, Anesthesiology and Pain Medicine, University of L'Aquila, L'Aquila, Italy
| | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila, L'Aquila, Italy
| | - Marco Valenti
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila, L'Aquila, Italy
| | | | - Laura Ursini
- "Casa Margherita" Hospice, ASL 01 Avezzano-Sulmona-L'Aquila, L'Aquila, Italy
| | | | - Federica Aielli
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
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Abstract
BACKGROUND The evidence supporting pharmacological treatment of death rattle is poor; yet, anticholinergic drugs feature in end-of-life care pathways and guidelines worldwide as a treatment option. AIM This qualitative arm of a wider study aimed to explore important issues which health-care professionals associated with decision-making to prescribe or administer anticholinergics at the end of life. DESIGN After purposive sampling, five focus groups were conducted. Discussions were audiotaped and transcribed verbatim. SETTING Thirty medical and nursing personnel working in inpatient and community settings from two specialist palliative care units in the United Kingdom took part in the study. RESULTS Thematic analysis of transcripts from audiotapes revealed perceived pressures to prescribe and/or administer anticholinergics from colleagues and carers, and drugs were often prescribed or administered in order to be seen to 'do something', although the benefit in terms of therapeutic response was considered minimal. Familiarity with drug regimens and dosing was often based on personal experience. The monitoring of side effects of anticholinergics at the end of life was recognised as problematic and had little influence on prescribing and administration. There was also an indication that patients and carers in the community were more likely to receive timely verbal preparation and explanation around death rattle than those cared for in an inpatient setting. CONCLUSION The study raises questions about the routine inclusion of anticholinergic treatment in UK end of life care pathways for the treatment of death rattle.
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Affiliation(s)
- Christine A Hirsch
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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Abstract
Anticholinergics, or antimuscarinic drugs, are drugs that competitively inhibit the action of acetylcholine at muscarinic receptors, leading to a blockade of the actions of the parasympathetic nervous system at sites where overactivity can lead to increased symptom burden. Successful blockade of the parasympathetic nervous system ultimately leads to decreased production of secretions in the salivary, bronchial, and gastrointestinal tracts. These effects are often used for several symptoms that originate due to parasympathetic nervous system overactivity, such as the "death rattle" and malignant bowel obstruction. Anticholinergic agents are divided into either tertiary amines or quaternary ammonium compounds, which differ in their ability to cross into the central nervous system. Quaternary compounds do not cross into the central nervous system and have a different adverse effect profile than the tertiary amines. The purpose of this review is to highlight anticholinergic agents, their pharmacology, and an evidence-based assessment of their role in palliative care.
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Affiliation(s)
- Eric Prommer
- Division of Hematology/Oncology, Mayo Clinic College of Medicine Mayo Clinic Hospital, Scottsdale, AZ 85054, USA.
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