What is the Death Rattle?

One of the more recognizable and often misunderstood signs of approaching death is the occurrence of terminal respiratory secretions, commonly referred to as the “death rattle.” This sound happens when mucous and saliva accumulate in the patient’s throat. As patients near the end of life, they may become too weak or lose consciousness, causing them to lose the ability to clear their throat or swallow.

When does the death rattle usually occur?

Terminal respiratory secretions are a sign that the patient is transitioning to the final stage of the dying process. At this point, their body naturally begins to conserve energy and many organ functions slow or cease.

While the death rattle can be distressing for families and caregivers to hear, there is no evidence to suggest that it causes discomfort or distress to the patient. The sound is simply a byproduct of the body’s natural decline, not an indication that the patient is choking or struggling to breathe. However, it’s important to understand that this symptom often signals that death is near.  

What does the death rattle sound like?

The death rattle sounds like a wet, gurgling, or rattling sound as patients breathe. This sound can resemble gentle bubbling or crackling and may vary in volume, often intensifying as breathing becomes more irregular. Though unsettling for those nearby, it does not indicate pain for the patient. 

How long until death after the death rattle?

The death rattle is often a predictor of imminent death in terminally ill patients. Research suggests that the median time from the onset of this symptom to death is approximately 16 hours. However, this timeframe can vary as each patient’s journey is unique. It may continue for as long as 24-48 hours.

Types of death rattles.

There are two types of death rattle, distinguished by the location and nature of the secretions:

• Oral secretions: This type occurs when saliva and mucus build up in the upper throat and mouth. The sound is often softer and more gurgling, resembling a wet, crackling noise. It can vary in intensity depending on the amount of fluid present.
• Bronchial secretions: This type is deeper and results from mucus accumulating in the lower airways, closer to the lungs. It tends to produce a louder, more pronounced rattling or bubbling sound. This can be particularly unsettling, but it still doesn’t cause discomfort to the patient.  

 Both types of death rattle occur because of the body’s weakening ability to manage secretions and are common indicators that the body is entering the final stages of life.

Factors that contribute to the development of death rattle.

Contributing clinical factors include:

• Hypersalivation from neuromuscular dysfunction, commonly seen in conditions like ALS or brain injuries.
• Medications that increase saliva production, such as pilocarpine, antipsychotics (like haloperidol and clozapine), and alprazolam.
• Impaired swallowing caused by reduced consciousness.
• Physical impairments such as GERD, upper respiratory infections (URIs), and gastrointestinal dysmotility. 

Death rattle treatment options.

Treatment options for managing the death rattle focus on reducing the buildup of secretions and providing comfort to both the patient and their loved ones. Non-pharmacological therapies should be considered first, including:

• Repositioning the patient: Gently turning the patient onto their side can help secretions drain naturally, reducing the sound of the rattle. Elevating the head slightly may also assist in clearing the airways.
• Reducing fluid intake: As death approaches, patients often no longer feel the need to eat or drink. Limiting fluid intake can help minimize the production of saliva and mucus, which can contribute to the death rattle.
• Suctioning: In some cases, gentle suctioning can be used to remove excess secretions. However, this is usually done sparingly, as it may cause discomfort and can stimulate more secretion production. 

 
Anticholinergic medications for treating death rattle.

When non-pharmacological methods fail to reduce secretions, anticholinergic medications can be considered to manage the death rattle. These drugs work by reducing the body’s fluid production and lessening the buildup of saliva and mucus that causes the rattling sound. Commonly used anticholinergics include:

• Scopolamine (available as a patch) 
  
• Atropine (administered as oral drops or injections) 
  
• Hyoscyamine
• Glycopyrrolate 

 While these medications can be helpful, the effectiveness is variable. There is no consistent data to suggest they are more effective than a placebo. Additionally, patients with pulmonary conditions are less likely to benefit from these medications. In fact, asthma patients should not take atropine due to excessive drying of bronchi.  

Side effects of anticholinergic medications.

Anticholinergic medications also cause several side effects including:  

• Hallucinations 
  
• Delirium 
  
• Confusion 
  
• Restlessness 
  
• Blurred vision/mydriasis 
  
• Flushed skin 
  
• Palpitations 
  
• Constipation 
  
• Tachycardia 
  
• Dry mouth 
  
• Urinary retention 

Tips for caring for a patient with a death rattle.

Once you understand what the death rattle is, it’s important to consider how to provide care and comfort for a patient experiencing it. Family members and caregivers can offer support by holding the patient’s hand and speaking softly to them, which can be reassuring, even if they are unresponsive. They can also maintain cleanliness by gently wiping away any secretions around the mouth to keep the patient comfortable.

What are some of the other signs that death is imminent?

In addition to terminal respiratory secretions (death rattle), there are several other signs that indicate death may be near:

• Cool extremities: The patient’s hands and feet may become increasingly cool to the touch as circulation slows. 
• Mottled skin: The skin may develop a blotchy, purplish appearance, especially on the legs and arms.
• Decreased appetite: The patient may lose interest in fluid or food, consuming little to none during this time.  

Contact Crossroads for support.

We understand how challenging this time this can be. When the Crossroads Hospice & Palliative Care team recognizes signs that a patient is nearing the end of life, our EvenMore Care^© program is activated. A dedicated member of our team will stay with the patient, offering compassionate care while supporting the family.
 
We’re here for you 24/7 – find a Crossroads location near you, use any contact methods in the help bar above, or access a free hospice checklist below.