Considering advance care planning as a repeated process of discussion of prognosis, concerns and probable preferences for care would be more useful than encouraging binding advance decisions. Further research should assess the effectiveness of this approach. Local coordination of who is responsible for information provision is needed, and greater involvement of patients with COPD in management decisions as they arise.

The management of 'death rattle' was reviewed by a task group on behalf of the Association for Palliative Medicine's Science Committee. Evidence was searched for the effectiveness of various anti-muscarinic drugs in drying oropharyngeal and bronchial secretions in dying patients. Clinical guidelines were constructed based on evidence from volunteer and clinical studies. Death rattle occurs in half of all dying patients and some response occurs in around 80% of treated patients. Clinical studies demonstrate that subcutaneous hyoscine hydrobromide 400 microg is more effective at improving symptoms at 30 min than glycopyrronium 200 microg by the same route. Volunteer studies demonstrate that intramuscular glycopyrronium 400 microg is as effective in drying secretions at 30 min as a dose of 200 microg given intravenously. Duration of response is shortest for hyoscine butylbromide (1 h) and longest for glycopyrronium (more than 6 h). There is insufficient evidence to support the use of one drug over another in a continuous infusion and prescribers should base decisions on different characteristics of each anti-muscarinic drug.

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Audible respiratory tract secretions in the dying patient are often referred to as the ‘death rattle’. This reflects the distressing nature of this symptom. The management of respiratory tract secretions in the dying patient is a challenge for all healthcare professionals involved in palliative care; this symptom can cause considerable distress for patients, their relatives and carers. A review of the literature was undertaken to identify the incidence and management of respiratory tract secretions. Research on this subject is limited and focuses on the pharmacological management. Only one study (Hughes et al, 1997) was identified that considered a non-pharmacological approach to treatment. This article discusses current practice in palliative care settings and examines the research relating to pharmacological management.

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