The Death Rattle of Suffering?

Sarah Stuppi
History of CAM
Fall 2007

"If we are really dying, let us hear the rattle in our throats and feel cold in the extremities;
if we are alive, let us go about our business."
Henry David Thoreau, Walden

"Next morning, around six o'clock, the servant entered the room with a candle. He
found his master lying on the floor, the pistol beside him, and blood everywhere.
He called, he touched him; no answer came, only a rattling in the throat."
Johann Wolfgang von Goethe, The Sorrows of Young Werther

"I think I may have dropped off into a light sleep, but my senses were still wide awake,
and I suddenly startled into intense consciousness by a hurried, angry sound, the most
awe-inspiring sound anyone can hear, the Death Rattle."
W. Somerset Maugham, The Razor's Edge

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The death rattle is the sound produced by oscillatory movements of secretions in

oropharynx, hypopharynx and trachea during respiration in unconscious terminal or
immobilized patients. This usually happens when the patient has become too weak to
swallow and has also lost the cough reflex. The death rattle has not been shown to be
harmful or distressing to a patient, is not a cause of death, and has been expressed in
literature throughout history. Even today there are references in books, poetry, and song
lyrics.
The introduction of pharmaceutical treatment for this symptom is, however, a new
phenomenon. There have been surveys to determine if relatives of dying patients find the
sound bothersome1, and subsequently a few clinical trials to determine which drug treats
death rattle the best2,7. This transformation of the death rattle from an ordinary
physiological occurrence to a pathological symptom that ethically demands treatment is
only one example of the condition branding that occurs too often and is jeopardizing
quality medical treatment in palliative care. Pharmaceutical companies are increasingly
transforming natural body functions such as death rattle into symptoms that they can
waste time and money on finding semi-effective treatments for, and then market the new
treatment.
Pharmaceutical intervention in Palliative care is a somewhat new occurrence.
According to the World Heath Organization, palliative care is an approach that improves
the quality of life of patients and their families facing the problem associated with lifethreatening illness3. Hospice care is end-of-life palliative care. Death rattle is usually
observed in patients in hospice care; therefore the patients involved in the clinical trials
testing various pharmaceutical drugs for death rattle are palliative care patients. The
drugs are mostly anti-cholinergic or muscarinic receptor blockers. The desirable side
effect of these drugs is the dry mouth to prevent the buildup of the secretions that cause
death rattle.
The death rattle sound has been used as an indicator throughout history to tell if a
person was near death. The sound was observed by relatives, friends, or a traveling
doctor, usually in the patients home. Treating the sound was not an option for people
until more recently, but even had it been possible, people likely would not have chosen to
as it could be a useful tool in determining if a person is near death. In some cases, it
seems that observation of the death rattle could be a relief to relatives of a suffering
person. Especially for religious or spiritual people who believe in karma or an afterlife,
hearing the death rattle means that their loved one is near the end of their suffering, and
this could be a very comforting thought.
The death rattle has become almost an archaic term; many people today dont
understand what it means, and its definition has changed through time. Its medical
1

Sound of death rattle I: are relatives distressed by hearing this sound?

Palliative Medicine.2006 Apr.; 20(3): 171-175.
The sound of death rattle II: how do relatives interpret the sound?
Palliative Medicine.2006 Apr.; 20(3): 177-181.
2

Hyoscine vs. glycopyrronium for drying respiratory secretions in dying patients.

British Journal of Community Nursing. 2005 Sep.;10(9): 421-426.
3

WHO definition of Palliative care: http://www.who.int/cancer/palliative/definition/en/

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definition today is different from the way that it is commonly used; for example, many
writers will refer to the end of something as the death rattle. For example, we heard the
death rattle of the Roman Empire and Soviet Russia, and we are now (metaphorically)
hearing the death rattle of George W. Bushs eight year presidential reign. Sports fans
hear the death rattle of their favorite teams seasons grow louder the more games the team
loses. These current uses of the term demonstrate its existence and acceptance in history
as a sound that denotes approaching death.
Pharmaceutical treatments must be given in anticipation of death rattle to prevent
the collection of saliva in the mouth and to dry the upper airway so the sound does not
have a chance to begin. Once the death rattle is observed, the drugs are not as effective in
eliminating it. Because most patients with death rattle are unable to swallow, these drugs
are usually given transdermally, subcutaneously, or intravenously4. One of the drugs that
has been tested and is considered for treating the death rattle is hyoscine hydrobromide,
also known as scopolamine. This drug has many uses; dry mouth is the desired side effect
to combat the death rattle, and another side effect is delirium. Scopolamine and hyoscine
are derivatives of atropine, from the Atropa belladonna plant. Atropine is used to treat
insecticide poisoning and as a side effect decreases secretions by blocking the vagal
reflexes. Scopolamine is used to treat nausea from motion sickness, spastic states and
similarly decreases secretions.

Scopolamine has a long and interesting history of use for a number of purposes. It
was used in Incan culture to kill people or for religious purposes. It has also been used in
forensics as a truth serum, because it was believed that if a person were in a delirious
mental state they would be unable to lie5. Scopolamine is used in modern Latin America,
especially Colombia and Venezuela as a date rape drug and to aid in robbery; it is a
particularly useful drug for this because it produces retrograde amnesia. People who are
drugged appear normal to others, but willingly empty their bank accounts at an ATM for a
stranger, because the drug has such strong hypnotic qualities. The drug is referred to as el

National Cancer Institute website:

http://www.cancer.gov/cancertopics/pdq/supportivecare/lasthours/Patient/page2#Keypoin
t14
5
Winter, Alison. The Making of Truth Serum. Bulletin of the History of Medicine. Fall
2005; 79(3):500-533.
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soplo del diablo- devils breath, and the plant from which it comes as the
borrachero-get you drunk- tree, because it is considered so dangerous6.
Glycopyrronium is another drug that has been tested, and found to be about as
effective as hyoscine when used preventatively; yet still twenty-eight percent of the
patients administered glycopyrronium, and forty-two percent of patients who received
hyoscine still die with RTS present. A study comparing glycopyrronium to hyoscine in its
efficacy in treating RTS, not for it potentially having fewer side effects: The study failed
to show any statistically significant difference in the use of sedatives between patients
treated with glycopyrronium compared to patients treated with hyoscine hydrobromide
despite the lack of sedating effects of glycopyrronium compared to hyoscine
hydrobromide7
It could be argued that seeing a relative spend the last hours of life in this
delirious state induced by a drug like scopolamine should be at least as distressing as the
death rattle sound itself. Especially because the tested pharmaceuticals are only effective
when used preventatively; even then not in all cases are the drugs effective in preventing
death rattle6, 7. Is it ethical to give a patient a delirium-inducing drug before they even
develop the symptom that the drug treats? Another article in the Journal of Palliative
Medicine, suggests not; or at least that if delirium does occur, it too can be treated:
Acetylcholine is one of the critical neurotransmitters in the
pathogenesis of delirium, and it may be that acetylcholine serves as
the final common neuro-transmitter pathwayThe relationship of
drugs to delirium is most clear for anticholinergic drugs with
muscarine receptor affinityPhysostigimine is known to be
helpful in the treatment of delirium caused by anticholinergic
toxicity8
To be fair, the article does state that the best defense against delirium is to avoid the use
of drugs which cause it; scopolamines use to treat death rattle is mentioned specifically
as an example of an unnecessary use of a delirium-inducing drug.
Would people rather notice the rattling of their dying relatives breath, or watch
them hallucinate? Many articles examining the treatment of the death rattle also identify
the value of explaining the sound to relatives, yet none has examined the efficacy of this
explanation alone in reducing their fears and anxieties.
The incidence of death rattle is anywhere between six and ninety-two percent in
dying patients. In seventy-five percent of the patients who exhibit this symptom, it is a
6

Ardila A, Moreno C. Scopolamine intoxication as a model of transient global

amnesia. Instituto Colombiano de Neuropsicologia Brain Cogn;1991 Mar.;15(2):
236-245 http://www.biopsychiatry.com/burundanga.htm

Heino Hugel, John Ellershaw. Respiratory Tract Secretions in the Dying Patient: A
Comparison between Glycopyrronium and Hyoscine Hydrobromide. Journal of Palliative
Medicine. 2006 Apr.; 9(2): 279-284.
8
Clare White, et al. First Do No HarmTerminal Restlessness or Drug-Induced
Delirium. Journal of Palliative Medicine. 2007 Apr.; 10(2): 345-351.
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positive indicator of death within forty-two hours9. This data could be skewed however,
in that the only take into account the statistics of death rattle occurrence for patients who
are in end of life care. If dying people who are cared for at home by family were
included, or people who developed the death rattle sound and were not terminal, the
results would invariably been different.
In the Journal of Pain and Symptom Management, a retrospective study examined
the most likely risk factors for developing a condition that is referred to as respiratory
tract secretions (RTS) which causes death rattle. These are: primary lung cancer,
prolonged dying phase, and male gender10. According to the article in Intensive and
Critical Care Nursing, death rattle is most commonly reported in patients dying from
pulmonary malignancies, primary brain tumors (gliomas) or brain metastases 9.
Regardless of the cause of death rattle, no randomized controlled trial has proven that a
pharmaceutical drug is completely effective in eliminating the sound.
One ethical argument for the use of pharmaceuticals in treating death rattle
compares two cases, one in which the death rattle was treated in a way the authors
believed was appropriate, and in the other case the death rattle was not treated. The
author concluded that there was considerably less distress among the relatives of the
treated patient. The problem with this conclusion is that the cases were markedly
different- the pharmaceutically treated man was 56 years old and died after having been
in a coma for some time, while the untreated woman was 38 years old and had undergone
multiple surgeries. Both had brain conditions; however, the woman was considerably
younger, and her family endured a more difficult process in that her terminal condition
was not known until after the surgeries, and the family had hope until that point. It seems
that much of the grief this family endured could easily have been due to the painful
process, and not simply from the death rattle sound2.
A two part questionnaire in 2006 published in Palliative Medicine1 determined
that relatives are disturbed by the sound of the death rattle, and that many people still
interpret this sound as approaching death. This is not always the case, however, as the
people interviewed in this study were relatives of someone receiving end-of-life care. It is
possible for individuals who are nowhere near death to develop the death rattle from
RTS, as it is simply a buildup of mucous and other fluids in the respiratory tract. This
sound sometimes occurs after mechanical ventilation is withdrawn, whether or not the
patient is going to die7. If relatives of patients in other situations were interviewed about
how they felt about the sound, the results could have been different; it seems that whether
a patient is terminal or not would greatly influence whether relatives are distressed by the
death rattle sound.
Nurses working in palliative care have also been surveyed to determine how they
feel about the death rattle sound. Interestingly, many believed that the noise should be
treated, often using suction to remove the secretions. Others felt most comfortable
treating death rattle using pharmaceuticals, and interestingly, only one nurse who
Erwin J.O. Kompanje. Death rattle after withdrawal of mechanical ventilation:
Practical and ethical considerations Intensive and Critical Care Nursing. 2006 Aug.;
22(4): 214-219.
10
Kss, Robin MartinEllershaw, John. Respiratory tract secretions in the dying patient: a
retrospective study. Journal of Pain and Symptom Management. 2003 Oct.; 26 (4): 897902.
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participated in the survey stated that repositioning of the patient to facilitate breathing is
an appropriate treatment11. It seems that this should be the most obvious, least harmful
and invasive, and most cost-effective method of treatment as opposed to suction or
injected medications or patches; yet for some reason drug treatments are becoming more
accepted as first-line treatments.
The number of treatments that are considered medically necessary has greatly
expanded in the last twenty years. Part of this can be explained by the greater number of
treatments that we have available; however, most of the increase in available medical
treatments (especially pharmaceutical drugs) can be attributed to the increase in money
allocated to the marketing of these treatments that become essential and required. If
pharmaceutical companies see a market for something, they can and will create a drug
that will make them a profit. If they have a drug that could be used to treat a symptom,
they market it in such a way to make sure that it gets used, even if they have to convince
people that it is ethically wrong to not do so.
In a 2006 article in Intensive and Critical Care Nursing, this statement was made:
The distressing experience and negative influence in the bereavement process indicates
an ethical demand to treat [death rattle] from the perspective of others merely than that of
the patient.6. Referring back to the WHO definition of palliative care, this statement
seems strangely true; it is the comfort of patients and their families that is of concern, not
merely the comfort of the patient alone. The article also states that patients are usually
not aware of their noisy breathing, and as long as they do no suffer, there is no ethical
demand to treat the symptom judged from the perspective of the patient 6.
How has it been determined that there is this ethical demand to treat death
rattle? There is already much controversy regarding issues in palliative medicine and
hospice care, that the treatment of the death rattle seems like a superfluous concern. The
bereavement process in itself is distressing, and there is not any concrete evidence that
indicates that the removal of one tiny aspect of death, such as the death rattle sound, will
make it any less distressing. Obviously, for a dying patient, the outcome is the same.
For relatives of a dying patient; however, the death rattle sound could potentially
add to the negative experience of watching someone die. However, because the drugs for
death rattle must be administered preventatively, have undesirable side effects, and that
non-pharmaceutical treatments such as suction and repositioning of patients are grossly
underused seems to point to a large flaw in palliative care practice. Were our ancestors
any less able to cope with death and the loss of loved ones simply because they could
hear the rattle in their throats before they died? Why are we attempting to distance
ourselves from death as much as possible?
Literature suggests that people in the past did experience the death rattle sound
and interpret it as disturbing; yet they accepted it as natural and even at times seemed to
welcome it when it would indicate that a dying loved one was nearing the end of their
suffering. The acceptance of the death rattle as a part of death is shown by its literary
uses, as well as its current use, yet we now think of it as a part of death that can be
eradicated.
Modern society has been so overexposed to the use of pharmaceutical drugs to not
only treat life-threatening conditions but to simply keep us comfortable, that the simple
Tessa Watts, et al. Palliative care nurses feelings about death rattle. Journal of Clinical
Nursing. 1999; 8: 615-618.
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acceptance of the death rattle being a part of life (or death) seems to have been lost to
history. The unwillingness of people to accept the death rattle, and the need to treat it at
the risk of serious side effects is an extreme example of peoples use of drugs to make
negative experiences easier. However, common and normal symptoms are now
considered conditions and, drug companies argue, should be treated to improve quality
of life- depression, anxiety, stress headaches, pre-menstrual syndrome, or the new and
more serious pre-menstrual dysphoric disorder are examples of common conditions
doctors treat. These conditions often do cause many people much discomfort that drugs
can help relieve, although this fact is obscured by over-diagnoses and over prescribing of
pharmaceuticals.
Death rattle, however, is a symptom that has been shown to bother only people
other than the patient. Regardless, because it has been demonstrated that death rattle is
distressing to people and therefore should be treated, it has become the ethical thing to
do. The easiest way is pharmaceutically, and it has been shown that nurses already prefer
this8. At what point in history death rattle became a pharmaceutically treatable symptom,
and other treatments such as patient repositioning were lost is hard to identify. It seems
we would have to find at what point we have become so dependent on a pill for
everything, which seems to have been a gradual transformation.
The method of administration of RTS drugs, the need for preventative use, and the
uniqueness of the symptom all could make it very easy for drug companies to formulate
easy to patent formulas. The transdermal scopolamine patch was utilized for the treatment
of death rattle as early as 198912. Companies have already established an ethical
consensus for why the drug should be used; they even have a label that sounds more
sophisticated than death rattle, RTS.
Drug companies want us to think that their goal is to eliminate suffering as much
as possible, although their motives are still obscured. The true objective here seems to be
to focus on eliminating only the suffering of people who can and will afford specialty
made anti-death rattle prevention, which offers to make death easier for those who care
for the dying person. Is it worth it all worth it when the only certainty about the
management of death rattle, treated or not, is death? It is difficult to argue that the world
would not be a better place without pain and suffering; but extending this idea to a
requirement for the treatment of any upsetting physical symptom, especially a symptom
of another person, seems to be a slippery slope. Where should the line be drawn between
helping an immediate need by treating a bothersome symptom, and depriving people of
the emotional maturity that can be gained from any natural experience, even something as
frightening as death?

Dawson, H R. The use of transdermal scopolamine in the control of death rattle. Journal
of Palliative Care.1989 Mar.; 5(1): 31-33.
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