Terminal respiratory secretions, commonly known as a “death rattle,” occur when mucous and saliva build up in the patient's throat. As the patient becomes weaker and/or loses consciousness, they can lose the ability to clear their throat or swallow.
The distinctive sound of end-of-life gurgling happens when an individual is no longer able to swallow or cough effectively enough to clear their saliva. They may make this sound as they are nearing the end of their life and while it can be painful to hear, it does not normally cause discomfort to the person.
This pattern or respirations is known as Cheyne-Stokes breathing, named for the person who first described it, and usually indicates that death is very close (minutes to hours).
As the moment of death comes nearer, the person's breathing may slow down and become irregular. It might stop and then start again or there might be long pauses or stops between breaths. This is sometimes known as Cheyne-Stokes breathing.
Gasping respiration in the dying patient is the last respiratory pattern prior to terminal apnoea. The duration of the gasping respiration phase varies; it may be as brief as one or two breaths to a prolonged period of gasping lasting minutes or even hours.
Agonal breathing or agonal gasps are the last reflexes of the dying brain. They are generally viewed as a sign of death, and can happen after the heart has stopped beating.
Terminal respiratory secretions occur as the body's breathing slows. This typically lasts no more than a few hours, but each patient is different and it can continue for as long as 24-48 hours. While the sound is difficult for family members to hear, it does not cause the patient pain or distress.
Death rattle usually becomes audible 24 to 48 hours before death (6,7). Reducing the distress among listeners has been conventionally treated through attempts to reduce or eliminate patient noise.
A conscious dying person can know if they are on the verge of dying. Some feel immense pain for hours before dying, while others die in seconds. This awareness of approaching death is most pronounced in people with terminal conditions such as cancer.
Cheyne-Stokes respirations are a rare abnormal breathing pattern. View Source that can occur while awake but usually occurs during sleep. The pattern involves a period of fast, shallow breathing followed by slow, heavier breathing and moments without any breath at all, called apneas.
Cheyne-Stokes breathing may be agonizing to watch, but it is not uncomfortable for the dying person. It is simply the body's way of compensating for physiological changes as the lungs, heart, kidney, liver, and brain start to fail in succession.
The clinical features of Cheyne-Stokes respiration are similar to congestive heart failure, including dyspnea, cough, and fatigue. A patient with Cheyne-Stokes respiration with heart failure shows more lethargy and fatigue due to increased sympathetic activity because of disturbed sleep.
Noisy Breathing (Terminal Secretions, Terminal Congestion)
The “wet” or “gurgling” sounds are caused by air passing over pooled oral and respiratory secretions the patient is no longer able to swallow or cough up – the patient may still be fully or partially conscious or unconscious.
Visions and Hallucinations
Visual or auditory hallucinations are often part of the dying experience. The appearance of family members or loved ones who have died is common. These visions are considered normal. The dying may turn their focus to “another world” and talk to people or see things that others do not see.
Agonal breathing is sometimes confused with a different phenomenon referred to as “death rattle.” Death rattle is more of a gurgling noise caused by mucus or saliva that is caught in the chest as a person is dying. By contrast, agonal breathing is an often brief period of abnormal breathing.
Pulse and heartbeat are irregular or hard to feel or hear. Body temperature drops. Skin on their knees, feet, and hands turns a mottled bluish-purple (often in the last 24 hours) Breathing is interrupted by gasping and slows until it stops entirely.
They might close their eyes frequently or they might be half-open. Facial muscles may relax and the jaw can drop. Skin can become very pale. Breathing can alternate between loud rasping breaths and quiet breathing.
Decompensation progresses over a period of minutes even after the pulse is lost. Even when vascular collapse is the primary event, brain and lung functions stops next. The heart is the last organ to fail.
For the first few minutes of the postmortem period, brain cells may survive. The heart can keep beating without its blood supply. A healthy liver continues breaking down alcohol. And if a technician strikes your thigh above the kneecap, your leg likely kicks, just as it did at your last reflex test with a physician.
Atropine, hyoscine butylbromide, or scopolamine are equally effective for the treatment of death rattle in terminal care.
Seriously ill patients encountered by hospice and palliative care clinicians are at risk for thirst due to dehydration, electrolyte disturbances, hypotension, xerostomia, and immobility which can impede access to water.
The term agony, deriving from the Greek ἀγωνία that means “fight”, defines the last moments of the living organism's existence before the encounter with death, and its phenomenology is still to be explored.