Death Rattle Research Articles

Dying from COVID-19 in nursing homes-sex differences in symptom occurrence

BackgroundCoronavirus disease 2019 (COVID-19), is a disease with diverse presentation. Several studies have shown different occurrence of symptoms for women and men, but no studies have been found examining sex differences in clinical presentation for nursing home residents dying from COVID-19.The objective of this study was to describe sex and age differences and the impact of a dementia diagnosis on symptom occurrence during the last week in life for persons dying from COVID-19 in nursing homes.MethodsThis is a population-based retrospective study based on data from the Swedish Register of Palliative Care. A total of 1994 residents aged 65 or older who died from COVID-19 in nursing homes were identified. The impact of sex, age and a dementia diagnosis on six different symptoms was analysed using chi2-test and multivariate logistic regression.ResultsResidents dying from COVID-19 were more often men (p < .002). Men more often had dyspnoea and death rattles (p < .001). Nausea was more common in women (p < .001). No sex differences in the occurrence of pain, anxiety or confusion were seen. Dyspnoea and nausea were less commonly reported in residents with dementia (p < .001).ConclusionsWe found sex differences in symptom presentation for fatal COVID-19 in nursing home settings which remained after adjusting for age. Residents with a dementia diagnosis had fewer symptoms reported before death compared to those without dementia.Clinical presentation of fatal COVID-19 differs between women and men in nursing homes. Residents with fatal COVID-19 present with more unspecific and less prominent symptoms when also suffering from dementia.

Republican Death Rattle

As Donald Trump blackened Washington on his way out of town, pundits lauded the end of Trumpism’s hold on the Republican Party. What they failed to see is that Trumpism is merely a reckless version of what Republicanism has been for some time.

Communication and Behavior of Palliative Care Physicians of Patients With Cancer Near End of Life in Three East Asian Countries

BackgroundThe characteristics of physician communication with patients at the end of life (EOL) in East Asia have not been well studied. We investigated physicians' communications with imminently dying patients with cancer and their families in palliative care units (PCUs) in Japan, South Korea, and Taiwan. MethodsThis observational study included patients with cancer newly admitted and deceased during their first admission to 39 PCUs in three countries. We evaluated 1) the prevalence and timing of informing patients and families of patients' impending death and 2) the prevalence of communication to assure the families of the patient's comfort. ResultsWe analyzed 2138 patients (Japan: 1633, South Korea: 256, Taiwan: 249). Fewer Japanese (4.8%: 95% confidence interval [95% CI], 3.8%–5.9%) and South Korean (19.6%: 95% CI, 15.2%–25.0%) patients were informed of their impending death, whereas 66.4% (95% CI, 60.2%–72.1%) of Taiwanese were informed; among all three countries, ≥90% of families were informed. Although most patients in all three countries and the families in South Korea and Taiwan were informed of the impending death greater than or equal to four days before death, 62.1% (95% CI, 59.6%–64.6%) of Japanese families were informed less than or equal to three days prior. Most families in all three countries received assurance that the patient would remain comfortable (could hear until death, no distress with death rattle or respiration with mandibular movement). ConclusionsPhysicians in Taiwan communicated about patient's impending death most frequently, and physicians in all three countries generally provided assurance to families that the patients would remain comfortable. Further studies should explore the reasons for these differences and the effects of such communications in East Asia.

Understanding relatives\u2019 experience of death rattle

BackgroundDeath rattle is a frequently occurring symptom in the last phase of life. The experience of death rattle of relatives has been found to vary. It is unclear if treatment with medication is useful. The most fitting solution for this symptom is still under debate.AimThis study aims to better understand the experience of relatives of their loved ones’ death rattle.DesignA qualitative interview study with a phenomenological approach was performed. Data were collected through semi-structured interviews which were audio recorded, transcribed and analyzed using qualitative content analysis.ParticipantsNineteen family members of 15 patients were interviewed.ResultsMost relatives had experienced death rattle as a distressing symptom. Concerns about how long the rattling would last resulted in more distress. Experience of death rattle was less fierce when other symptoms such as pain or dyspnea prevailed. Hearing the sound of death rattle sometimes reminded relatives of previously witnessed dying trajectories, which seemed to increase their current level of distress. The experience of death rattle is not always influenced by the amount and quality of information given about the symptom.ConclusionDeath rattle is a stressful symptom and the experience of relatives is influenced by more factors than the sound itself. Communication and information alone seem inefficient to address relatives’ distress. The best approach for dealing with this symptom is unclear. Further research needs to show if prophylactically given drugs may be helpful in its prevention.

Palliative care physicians' perspectives of management for terminally ill cancer patients with death rattle: a nationwide survey.

Death rattle occurs during the last days of life, and relatives of those afflicted frequently report that it is very distressful. However, there is no effective treatment for it. The purpose of this study was to investigate the perceptions of Japanese palliative care physicians in clinical practice in Japan. We conducted a nationwide survey of 268 physicians via an anonymous, self-report questionnaire. We assessed pharmacological and non-pharmacological management and anticholinergic agent choice. One hundred eighty-nine physicians (70.5%) returned the questionnaires. Fifty-five participants (29.1%) treating patients with Type-1 (real death rattle) and 36 participants (19%) treating patients with Type-2 (pseudo-death rattle) death rattle reported that they would frequently administer an anticholinergic agent. One-fourth would administer scopolamine butylbromide or scopolamine hydrobromide. In conclusion, more Japanese palliative care physicians thought that anticholinergic agents might be effective for treating Type-1 death rattle rather than Type-2. Further clinical trials of these agents are needed.

When they stop drinking-examining end-of-life hydration practices and death rattle occurrence.

To characterize the practice of subcutaneous hydration provision in the Beer-Sheva home care hospice unit. We also explore the potential connection between the provision of subcutaneous hydration and the incidence of death rattle. This was a prospective observational study involving 120 hospice patients. During the 6days before death, hospice staff recorded whether or not fluids were administered orally and/or subcutaneously; the duration, timing, and quantity of fluid administration; the incidence, timing, and duration of death rattle; and whether medications that can affect death rattle were given. Fifty-three percent of the patients received subcutaneous hydration. The mean daily volume administered in the hydration group was 434ml. There was a significant association between the duration of treatment in the hospice unit and provision of subcutaneous hydration (mean of 51days in hydration group vs. 31days in non-hydration group, p = 0.03). Although not statistically significant, males were more likely to receive subcutaneous hydration than females (62% of males vs. 46% of females, p = 0.09). There was a higher incidence of death rattle in men compared to women (54.7% in men vs. 32.8% in women, p = 0.025). A statistically significant association between death rattle and the provision of subcutaneous hydration wasn't demonstrated. The decision of whether to provide subcutaneous hydration is individualized taking into consideration the values of the patients and their families. The provision of 500ml per day of subcutaneous saline during the last 6days of life does not significantly increase the incidence of death rattle.

The top ten things that must be known about end of life therapy in patients with advanced cancer

End of life is an issue that affects every human being sooner or later. Several aspects at the end of life should not be neglected to achieve good symptom control. Basic knowledge and skills on symptom control and palliative care are important to support patients in this threatening phase of their life. Palliative care should not be provided only at the end of life. The concept of early integration of palliative care is increasingly coming into focus. Nevertheless, at the end of life there are some important facts and issues that should be taken into account. This short article provides a list of ten important facts at the end of life that are important for the authors. Prognostication, early integration, benzodiazepines, death rattle, palliative sedation, standard therapy for refractory dyspnea, opioids in renal failure, psylocibin, denial and reduction of drugs at the end of life will be discussed in detail.

Between Pen and Pixel: Comics, Materiality, and the Book of the Future by Aaron Kashtan

Reviewed by: Between Pen and Pixel: Comics, Materiality, and the Book of the Future by Aaron Kashtan Daniel F. Yezbick (bio) Aaron Kashtan, Between Pen and Pixel: Comics, Materiality, and the Book of the Future. The Ohio State University Press, 2018. 224 pp, $29.95, $104.95. Between Pen and Pixel is a remarkable work of critical insight and theoretical synthesis. As previous high profile reviews, including Vincent Haddad's "My Bookish Upbringing" from the 6 July 2019 L. A. Review of Books have observed, Kashtan's meticulously organized project cuts through the ongoing claptrap and clickbait associated with anxious assumptions and inane lamentations over the digitized death rattle of the traditional codex Book and/or its multimodal cousins, the Comics. Instead of blanket statements and generalized accusations, Kashtan methodically reveals a rich, cross-disciplinary interplay of narrative synergies that are as productive, informative, and inclusive as they are encouraging and, at times, downright playful in their positivity. Kashtan's work also arrives at a pivotal point in both comics history and comics scholarship, providing multiple frameworks of inquiry and understanding that can bridge the oceans of 20th century newsprint floppies, [End Page 127] trades, and graphic novels and the multitudes of digitally app-marketed, tablet-bound, and web-derived variants of 21st century comics. For the eager comics scholar, there are abundant pleasures throughout, including Kashtan's shrewd re-assessment of the complex negotiations of family artifacts and narrative materiality within Alison Bechdel's Fun Home; his systemic analysis of the contrasting analog and digital elements of Chris Ware's Building Stories; and perceptive discussions of how comics like Paul Tobin and Colleen Coover's Bandette, Randall Munroe's xkcd, Alex Robinson's Box Office Poison, Carla Speed McNeil's Talisman, and Lynda Barry's "instructional trilogy" (Picture This, What It Is and Syllabus) respond to the "Crisitunity" of materiality that continues to inspire and confound the interaction of print and digital platforms and their readerships. Kashtan's fresh, inviting approach to the conditions of creation, interpretation, and commerce drive his analyses of many diverse works from Dan Slott and Michael Allred's Silver Surfer to Amaranth Borsuk and Brad Bouse's Between Page and Screen. I am especially grateful for the project's intricately detailed assessments of the meta-narrative dynamics of Matt Kindt's Mind MGMT and Jason Shiga's Meanwhile. Each are among the finest close readings of key works by auteur creators in recent comics scholarship. In these and other moments, the book teems with an infectious love for its sequential subjects and their transmedial pleasures and provocations. At times, Between Pen and Pixel cannot help but indulge in the playful consanguinity of forms and stories it so cherishes. Thus, sly cryptographic games emerge out of its dissection of Matt Kindt's cunning use of codes and secret messages, and Kashtan's ingenious narratological assessment of gamebook design includes its own interactive "Choose Your Own" critical outcome option. These wry and inviting moments are not only compelling examples of his larger arguments about the inter-fertilization of material and digital codes, frames, and puzzles, but also a genuine sign of Kashtan's own life-long intimacy with the material and its benefits to readers, students, and teachers of story. He first makes these concerns explicit in the introductory section, "Who Should Read This Book and Who Wrote It," but the greater pay-off comes in three later sections relating to the instructional value and empowering potential of self-conscious textual literacy. Kashtan's final chapter, "Applications for Studying and Teaching Comics," is, like much of his work, personal and compelling in its recounting of various pedagogical experiences relating to materiality, narrative, and curriculum development. Yet, Between Pen and Pixel's greatest achievement—its most rewarding attention to its guiding focus on the materiality of comics/media—are the critical successes of Chapter 4, "Guided View: How Comics Move from Print to Digital and Back," and Chapter 5, "Between Panel and Screen: Comics That are Print and Digital at Once." In both chapters, intrepid close readings are used to dynamic effect, illustrating how transmedial, or remediated, or sequential simulacra of various forms reveal tensions of back...

Death rattle: reassuring harbinger of imminent death or a perfect example of inadequacies in evidence-based practice

Death is the inevitable consequence of life. Although clinicians are unlikely to accurately pinpoint when death is likely to occur in the people they care for, the death in a person with a diagnosis of malignant and nonmalignant tends to involve a period of predictable progressive clinical and functional deterioration. During this time, it is common for death rattle to occur. Due to its presentation, death rattle can cause stress and distress to caregivers. This often prompts clinicians to consider medical interventions that are not only ineffective in treating the problem but may also do harm. There is a dearth of research related to the management of death rattle. The article discusses the existing evidence in the management of death rattle, considerations for clinicians in the absence of reliable evidence and suggests areas for future research.

Hydration and symptoms in the last days of life

ObjectivesAt the end of life oral fluid intake is often reduced. Consensus about the most appropriate management for terminally ill patients with limited oral fluid intake is lacking. The objective...

The Past, Present, and Future of Accounting History

ABSTRACT This paper seeks to establish statistically and explain the past, present, and likely future of accounting history. The article is based on a recently constructed database of publications in accounting history from 1989 to 2016. The data reveal that the output of accounting history articles grew very rapidly in the 1980s and 1990s attributed to the increased demand from the profession for accountancy teaching in universities, out of which emerged a relatively small number of accountancy academics who took an interest in history. From the turn of the millennium the output of articles has gone into a slow secular decline largely because the growth of accountancy teaching at universities has stalled. If the downward trend continues, the viability of the discipline is threatened. However, action might be taken at least to slow the “death rattle” of accounting history feared by Radcliffe; and some suggestions for doing so are made.

Assuaging listener distress from patient death rattle.

Death rattle is a naturally occurring patient condition during the last hours of life developing in about 45% of patients (1,2).

Scopolaminebutyl given prophylactically for death rattle: study protocol of a randomized double-blind placebo-controlled trial in a frail patient population (the SILENCE study)

BackgroundDeath rattle (DR), caused by mucus in the respiratory tract, occurs in about half of patients who are in the dying phase. Relatives often experience DR as distressing. Anticholinergics are recommended to treat DR, although there is no evidence for the effect of these drugs. Anticholinergic drugs decrease the production of mucus but do not affect existing mucus. We therefore hypothesize that these drugs are more effective when given prophylactically.MethodsWe set up a randomized double-blind, placebo-controlled, multi-center study evaluating the efficacy of prophylactically given subcutaneous scopolaminebutyl for the prevention of DR in the dying phase. The primary outcome is the occurrence of DR defined as grade ≥ 2 according to the scale of Back measured by a nurse at 2 consecutive time points with an interval of 4 h. Secondary outcomes include adverse effects, quality of dying, quality of life in the last three days and bereavement. A sub-study will explore the experience of participating in a clinical trial in the dying phase from the perspective of relatives. Four hospices will include 200 patients.DiscussionThis is the first double-blind placebo-controlled study to prevent DR in patients in the hospice setting. Research in dying patients is challenging. We will apply ethical and organizational strategies as suggested in the literature.Trial registrationThe trial is retrospectively registered in the Dutch Trial register, identifier NTR 6438 June 2017. EudractCT number 2016–002287-14.

Hyoscine Butylbromide for the Management of Death Rattle: Sooner Rather Than Later

ContextDeath rattle (DR) is a dramatic sign in the dying patient. Existing studies with anticholinergic agents are controversial, as this class of drugs has been commonly administered without considering the rationale of the mechanism of action. A meaningful use of these drugs may provide a better outcome. ObjectivesThe aim of this study was to assess the efficacy of hyoscine butylbromide (HB), given prophylactically in comparison with HB administered once DR occurs. MethodsDying patients having a score of ≥3 in the Richmond Agitation-Sedation Scale—palliative version were included in the study. HB (60 mg/day) was given when DR occurred (Group 1) or as pre-emptive treatment (Group 2). The onset of DR (death rattle free time) and intensity of DR were recorded at intervals until death. ResultsEighty-one and 51 patients were randomized to Group 1 and 2, respectively. Patients in Group 2 survived longer than those in Group 1 (P < 0.05). DR occurred in 49 (60.5%) and three patients (5.9%) in Group 1 and 2, respectively (P = 0.001). A significant difference in the number of patients reporting DR was found at intervals examined (30 minutes, one hour, and then every six hours until death [P = 0.001]). In Group 1 and 2, DR free time was 20.4 (20.5) and 27.3 hours (25.2), respectively (P = 0.001). In Group 1, the treatment was considered effective in 10 patients (20.4%) only, after a mean of 14.4 hours (SD 8.57). ConclusionThe prophylactic use of HB is an efficient method to prevent DR, whereas the late administration produces a limited response, confirming data from traditional studies performed with anticholinergics. This could be considered a new paradigm to manage a difficult and dramatic sign, such as DR.

A retrospective medical records review of risk factors for the development of respiratory tract secretions (death rattle) in the dying patient.

Identification of risk factors predicting the development of death rattle. Respiratory tract secretions, often called death rattle, are among the most common symptoms in dying patients around the world. It is unknown whether death rattle causes distress in patients, but it has been globally reported that distress levels can be high in family members. Although there is a poor evidence base, treatment with antimuscarinic medication is standard practice worldwide and prompt intervention is recognized as crucial for effectiveness. The identification of risk factors for the development of death rattle would allow for targeted interventions. A case-control study was designed to retrospectively review two hundred consecutive medical records of mainly cancer patients who died in a hospice inpatient setting between 2009-2011. Fifteen potential risk factors including the original factors weight, smoking, final opioid dose and final midazolam dose were investigated. Binary logistic regression to identify risk factors for death rattle development. Univariate analysis showed death rattle was significantly associated with final Midazolam doses and final opioid doses, length of dying phase and anticholinergic drug load in the pre-terminal phase. In the final logistic regression model only Midazolam was statistically significant and only at final doses of 20mg/24hrs or over (OR 3.81 CI 1.41-10.34). Dying patients with a requirement for a high dose of Midazolam have an increased likelihood of developing death rattle.

Systematic review and narrative summary: Treatments for and risk factors associated with respiratory tract secretions (death rattle) in the dying adult.

To identify effective treatments and risk factors associated with death rattle in adults at the end of life. The presence of noisy, pooled respiratory tract secretions is among the most common symptoms in dying patients around the world. It is unknown if "death rattle" distresses patients, but it can distress relatives and clinicians. Treatments appear unsatisfactory, so prophylaxis would be ideal if possible. Quantitative systematic review and narrative summary following Cochrane Collaboration guidelines. CINAHL, MEDLINE, Health Source Nursing and Web of Science were searched for international literature in any language published from 1993 - 2016 using MeSH headings and iterative interchangeable terms for "death rattle". Randomized controlled trials were appraised using the Cochrane Collaboration's tool for assessing risk of bias. Non-randomized studies were assessed using ROBINS-I tool for assessing risk of bias in non-randomized studies of interventions. Instances of treatment and risk were extracted and relevant key findings extracted in line with Cochrane methods. Five randomized trials and 23 non-randomized studies were analysed. No pharmacological or non-pharmacological treatment was found superior to placebo. There was a weak association between lung or brain metastases and presence of death rattle, but otherwise inconsistent empirical support for a range of potential risk factors. Clinicians have no clear evidence to follow in either treating death rattle or preventing it occurring. However, several risk factors look promising candidates for prospective analysis, so this review concludes with clear recommendations for further research.

Continuation of non-essential medications in actively dying hospitalised patients

ObjectiveThe objective of this analysis was to examine the use of 11 non-essential medications in actively dying patients.MethodsThis was a planned secondary analysis of data from the Best Practices for...

Frequency of symptoms and drug treatment among dying patients in the last 24 hours of life at Landspitali - The National University Hospital of Iceland and in nursing homes

The purpose of this study was to evaluate the frequency of 5 common symptoms and drug treatments prescribed and given in the last 24 hours of life in 11 medical units at Landspitali National University Hospital of Iceland (LUH) and in 7 nursing homes (NH). Data was collected retrospectively from 232 charts of patients who died in 2012, using documentation in the Liverpool Care Pathway (LCP) and the medication management system. About half of the patients died at LUH with similar gender ratio but 70% of patients in NH were women. The LCP was used for 50% of all deaths at LUH and 58% in NH. In 45% of all deaths LCP was used for 24 hours or less. The most common symptoms were pain (51%), agitation (36%) and respiratory tract secretions (36%). Frequency of symptoms was similar between institutions and age groups. Cancer patients had significantly higher incidence of agitation and were prescribed and given higher doses of morphine compared to other groups. Regular medication for agitation was haloperidol (45%), diazepam (40%) and midazolam (5%). Close to 70% of the patients were treated with a scopolamin patch for death rattle. A large number of patients have symptoms in the last 24 hours of life both in hospital and in nursing homes. Symptom control can be improved by adjusting morphine doses to patients need, using regular doses of benzodiazepine for agitation and better use of anticholinergic medication for death rattle. Key words: symptoms, medication, dying patients, last 24 hours of life, hospital, nursing homes. Correspondence: Svandis Iris Halfdanardottir, svaniris@landspitali.is.

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Treatment Recommendations for Respiratory Symptoms in Cancer Patients: Clinical Guidelines from the Japanese Society for Palliative Medicine.

Respiratory symptoms, dyspnea, cough, and death rattle, are common and distressing in advanced cancer patients. Palliation of respiratory symptoms is important to improve quality of life in cancer patients and their families/caregivers. Currently published clinical guidelines for the management of these respiratory symptoms in cancer patients did not cover the topics comprehensively or were not based on formal process for the development of clinical guidelines. The Japanese Society for Palliative Medicine (JSPM) decided to develop comprehensive clinical guidelines for the management of respiratory symptoms in cancer patients following the formal guideline developing process. This article provides a summary of the recommendations with the rationales, as well as a short summary of the developing process, of the JSPM respiratory symptom management guidelines. We established 26 recommendations and all recommendations are based on the best available evidences and expert consensus. More future clinical researches and continuous guideline updates are required to improve the quality of respiratory symptom management in cancer patients.