How Should We Conduct and Interpret Phase III Clinical Trials in Palliative Care?

Abernethy, Amy P.; Clark, Katherine; Currow, David C.

doi:10.1016/j.jpainsymman.2009.08.003

Cited by 3 publications

(4 citation statements)

References 6 publications

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“…We agree with others 20,23,34 who believe that there is a need for further well-designed prospective trials comparing the effectiveness of antimuscarinic medications with placebo. Until such trials are able to demonstrate a significant effect, recommendations for routine use of antimuscarinic medications can be questioned.…”

Section: Discussionsupporting

confidence: 72%

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Randomized Double-Blind Trial of Sublingual Atropine vs. Placebo for the Management of Death Rattle

Heisler

Hamilton

Abbott

et al. 2013

Journal of Pain and Symptom Management

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Section: Discussionsupporting

confidence: 72%

“…To put the results of these reports into proper context, knowledge of the natural course of death rattle is essential. 20 Administration of antimuscarinic medication is not without potential risks. Antimuscarinic agents may cause dry mouth, urinary retention, agitation, confusion, delirium, tachycardia, and so forth.…”

Section: Introductionmentioning

confidence: 99%

Randomized Double-Blind Trial of Sublingual Atropine vs. Placebo for the Management of Death Rattle

Heisler

Hamilton

Abbott

et al. 2013

Journal of Pain and Symptom Management

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“…15,17,25 The impact of death rattle on families and caregivers, especially the suggestion that families are disturbed by the sound, is of central importance to this discussion for 2 reasons: treatment is often initiated based on the perceived distress of family members, 1,18,25 and perhaps most significantly, there is as yet no compelling scientific evidence that our interventions for death rattle are effective. 1,6,19,26 This presents an ethical dilemma in that using these drugs involves giving potentially ineffective treatment to an individual who is likely unconscious and unable to give consent or report adverse effects, and treatment may be initiated based on the emotional and psychological distress of the clinician or family member. 6 It also presents a clinical dilemma in which the natural course of the symptom is unknown, and the most appropriate intervention has yet to be determined.…”

Section: Impact On Families and Caregiversmentioning

confidence: 99%

“…Reprinted with permission. Journal of Hospice & Palliative Nursing www.jhpn.comthat commonly used anticholinergic medications may all be equally ineffective in treating death rattle 2,4,13,19. …”

mentioning

confidence: 99%

The Death Rattle Dilemma

Fielding¹,

Long²

2014

Journal of Hospice & Palliative Nursing

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Death rattle, defined as the noise created by the flow of air through secretions in the upper respiratory tract, is a well-known phenomenon associated with the dying process. The use of anticholinergics is standard practice in hospice and palliative care, yet despite a growing number of quality clinical trials, there is still no compelling scientific evidence that our interventions for death rattle are effective. Studies to date have focused on antisecretory agents, primarily anticholinergics, with mixed results and variable interpretations. Recent placebo-controlled data suggest that death rattle may tend to diminish over time without medication. Objective measurements of patient distress indicate that dying patients experience very low levels of respiratory distress with or without death rattle. While treatment is often initiated based on the perceived distress of family members, emerging qualitative data suggest that death rattle is not always distressing to family and caregivers. Our current approach to death rattle presents a clinical and ethical dilemma; a better understanding of the range of responses and interpretations will allow nurses to frame the discussion of death rattle more effectively and help to guide care. More research is needed into nonpharmacologic, particularly communication-based, interventions for death rattle. KEYWORDSanticholinergic, communication, death rattle, dying, symptom management Case StudyMr E. was 66 years old with advanced gastric lymphoma and was dying at home, being cared for by his family. He was somnolent, but his respirations were unlabored, and lung sounds were clear. The hospice nurse educated his family on the signs and symptoms of active dying and the use of comfort medications, including 1% atropine eye drops to be given sublingually as needed for respiratory secretions. SIGNIFICANCEAlternately referred to in the literature as terminal congestion, retained secretions, noisy breathing, and respiratory tract secretions, death rattle is well known as a phenomenon associated with the dying process. Although the term death rattle may seem macabre, it is a pragmatic expression for a common occurrence at end of life and has the advantage of being both descriptive and widely recognizable. The varied terminology reflects a divergent body of research, the cumulative results of which have yet to define a criterion standard of treatment. This is due in part not only to inconsistent terminology, but also to the variable quality and conflicting findings between studies. 1 Despite barriers to research in dying patients, there is growing evidence to suggest a lack of utility of our treatments for death rattle. 2-6 This is especially important in light of research indicating that treatment is often given to alleviate the distress of family and caregivers, including health care professionals, while those who hear it are not always distressed by the sound. 7,8 In fact, objective measures indicate low levels of respiratory distress in dying patients and no difference in distress betwee...

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