The final stage of life often brings about changes that can be unsettling for loved ones, including noisy breathing. This sound, known clinically as terminal secretions, is a natural phenomenon that occurs as the body prepares for death. Understanding this process helps caregivers and family members focus on providing comfort and support.
Defining Terminal Secretions
Terminal secretions refer to the gurgling, wet sound produced by air moving over accumulated saliva and mucus in the upper airway of a person nearing death. This phenomenon is frequently called the “death rattle,” though healthcare professionals often prefer “end-of-life respiratory congestion.” The sound is a sign that the body is shutting down and typically occurs in the final hours or days of life. While the sound can be distressing for those present, the person experiencing it is generally unaware and not in pain or distress.
The Underlying Physiological Cause
The accumulation of secretions occurs because the body loses the muscular strength and coordination required to manage its own fluids. As consciousness decreases, the patient’s natural protective reflexes, such as the cough and gag reflexes, become impaired or stop working. Normal production of saliva and mucus, which is typically swallowed, begins to pool in the back of the throat and upper trachea.
Generalized muscle weakness prevents the patient from effectively clearing these fluids. Turbulent airflow over the pooled secretions during inspiration and expiration creates the characteristic rattling noise. Since the patient is often deeply unconscious, they lack the physical ability or awareness to clear their throat or change position to allow natural drainage. This pooling is a passive process resulting from the body’s systemic decline, not an active respiratory struggle.
Practical Steps for Management
The primary goal in managing terminal secretions is to minimize the sound for the comfort of the family and to ensure the patient remains comfortable. Non-pharmacological measures are the first line of action for caregivers. Simply repositioning the patient often helps manage the secretions by using gravity to facilitate drainage.
Caregivers should gently turn the patient onto their side, a position known as a lateral position, or elevate the head of the bed slightly. This adjustment helps accumulated saliva and mucus pool higher or drain more easily, reducing the noise created by air movement. Gentle oral hygiene, such as swabbing the mouth to remove surface secretions, can also provide comfort and reduce the overall fluid volume. Deep suctioning should generally be avoided, as this intervention can irritate the patient and may stimulate more mucus production rather than providing sustained relief.
If repositioning and oral care are not sufficient to manage the distress caused by the noise, medical professionals may consider pharmacological interventions. The most common medications used are anticholinergic agents, which block the parasympathetic nerve impulses that stimulate the production of new secretions. Medications such as scopolamine, atropine, or glycopyrrolate are often administered to help dry up the fluid. These medications do not clear accumulated secretions, but they slow the production of new saliva and mucus.
The specific choice of medication depends on the patient’s condition and the care setting. Atropine and scopolamine can cross the blood-brain barrier and may cause minor sedation or delirium. Glycopyrrolate does not cross this barrier and is less likely to have central nervous system side effects. Family members should be continually reassured that the sound indicates neither pain nor respiratory distress, but is a predictable part of the final hours of life.