Individual research recommendation details

Recommendation ID

NG31/3

Question

Noisy respiratory secretions:- In people considered to be in the last few hours and days of life, are antisecretory anti-muscarinic drugs (used alongside nursing interventions, such as repositioning and oropharyngeal suction) better at reducing noisy respiratory secretions and patient, family and carer distress without causing unwanted side effects, than nursing interventions alone?

Any explanatory notes
(if applicable)

Why this is important It is common for people to experience noisy respiratory secretions at the end of life and the so called 'death rattle' is a predictor of death. The noise can cause considerable distress for people important to the dying person, both at the time and possibly after death, because of concerns that the person may have drowned or suffocated to death. Clinicians may administer subcutaneous anti-muscarinic agents in an attempt to 'dry up' secretions and relieve any distress primarily to people important to the person despite a lack of evidence of any beneficial effect to the patient or improvement in distress levels.

The evidence for the efficacy of pharmacological interventions in managing respiratory secretions is of low quality, and it is not clear if any one drug is more effective than another or if drugs are more effective than non-pharmacological approaches such as repositioning or oropharyngeal suction. Most studies involved low numbers of patients and were primarily based on cancer patients in hospices and so may not reflect the larger numbers of patients dying with non-malignant diseases in hospitals and in community care.

Anti-muscarinic agents may have undesired side effects, such as dry mouth, blurred vision or urinary retention, as well as a cost implication, and it is therefore hard to justify their continued use given the limited evidence base.

A randomised controlled trial is proposed comparing antisecretory anti-muscarinic drugs and nursing care to nursing care alone. Nursing interventions include repositioning, mouth care and education and reassurance for those important to the dying person. Outcomes of interest are subjective and objective measures of reduction in noise level, reduction in distress to the dying person or those important to them and adverse effects.

Source guidance details

Comes from guidance

Care of dying adults in the last days of life

Number

NG31

Date issued

December 2015

Other details