Lessons from the Literature

2021; Volume 22, No 11, November

Under My Microscope

IAHPC Research Advisor Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worthwhile.

Dr. Tania Pastrana. Used with permission.

By Dr. Tania Pastrana
IAHPC Research Advisor

Effect of Prophylactic Subcutaneous Scopolamine Butylbromide on Death Rattle in Patients at the End of Life: The SILENCE Randomized Clinical Trial

van Esch HJ, van Zuylen L, Geijteman ECT, Oomen-de Hoop E, Huisman BAA, Noordzij-Nooteboom HS, Boogaard R, van der Heide A, van der Rijt CCD. JAMA 2021; 326(13): 1268-1276. DOI: 10.1001/jama.2021.14785

Two years ago Lokker et al.1 published a review on treatment of death rattle. Death rattle is a frequent symptom, difficult in its treatment, and produce high the level of distress for those who hear it: family members, caregivers, health care personnel, and other patients. (Studies indicated that death rattle may not cause distress in patients.)

The team, led by van Esch in the Netherlands, conducted the SILENCE (Scopolamine Butylbromide Given Prophylactically for Death Rattle) trial to determinate whether administration of prophylactic scopolamine butylbromide (also known as hyoscine butylbromide) reduces the occurrence of death rattle.

The study had two patient groups: one received 20 mg of subcutaneous scopolamine butylbromide four times a day (n = 79), the other received a placebo (n = 78). The researchers found that among patients near the end of life, prophylactic subcutaneous scopolamine butylbromide, compared with placebo, significantly reduced grade 2 or higher of death rattle based on Back’s noise score scale.2

A frequent argument for use of prophylaxis—as we know, pharmacological treatment does not dry up already formed secretions—is that the death rattle does not cause suffering in the patient (who is the focus of care), and the use of anticholinergics may have other effects, such dry mouth or urinary retention. I found it interesting that these events were not significantly higher in the experimental group.

I invite you to read this study, which can help to improve the quality of the unit of care.

  1. Lokker ME, van Zuylen L, van der Rijt CCD, van der Heide A. Prevalence, Impact, and Treatment of Death Rattle: A systematic review. J Pain Symptom Manage 2014; 47(1): 105-122.
  2. Back IN, Jenkins K, Blower A, Beckhelling J. A Study Comparing Hyoscine Hydrobromide and Glycopyrrolate in the Treatment of Death Rattle. Palliat Med 2001; 15: 329-336.

Link to article

Importance Death rattle, defined as noisy breathing caused by the presence of mucus in the respiratory tract, is relatively common among dying patients. Although clinical guidelines recommend anticholinergic drugs to reduce the death rattle after nonpharmacological measures fail, evidence regarding their efficacy is lacking. Given that anticholinergics only decrease mucus production, it is unknown whether prophylactic application may be more appropriate.

Objective To determine whether administration of prophylactic scopolamine butylbromide reduces the death rattle.

Design, Setting, and Participants A multicenter, randomized, double-blind, placebo-controlled trial was performed in 6 hospices in the Netherlands. Patients with a life expectancy of 3 or more days who were admitted to the participating hospices were asked to give advance informed consent from April 10, 2017, through December 31, 2019. When the dying phase was recognized, patients fulfilling the eligibility criteria were randomized. Of the 229 patients who provided advance informed consent, 162 were ultimately randomized. The date of final follow-up was January 31, 2020.

Interventions Administration of subcutaneous scopolamine butylbromide, 20 mg four times a day (n = 79), or placebo (n = 78).

Main Outcomes and Measures The primary outcome was the occurrence of a grade 2 or higher death rattle as defined by Back (range, 0-3; 0, no rattle; 3, rattle audible standing in the door opening) measured at 2 consecutive time points with a 4-hour interval. Secondary outcomes included the time between recognizing the dying phase and the onset of a death rattle and anticholinergic adverse events.

Results Among 162 patients who were randomized, 157 patients (97%; median age, 76 years [IQR, 66-84 years]; 56% women) were included in the primary analyses. A death rattle occurred in 10 patients (13%) in the scopolamine group compared with 21 patients (27%) in the placebo group (difference, 14%; 95% CI, 2%-27%, P = .02). Regarding secondary outcomes, an analysis of the time to death rattle yielded a subdistribution hazard ratio (HR) of 0.44 (95% CI, 0.20-0.92; P = .03; cumulative incidence at 48 hours: 8% in the scopolamine group vs 17% in the placebo group). In the scopolamine vs placebo groups, restlessness occurred in 22 of 79 patients (28%) vs 18 of 78 (23%), dry mouth in 8 of 79 (10%) vs 12 of 78 (15%), and urinary retention in 6 of 26 (23%) vs 3 of 18 (17%), respectively.

Conclusions and Relevance Among patients near the end of life, prophylactic subcutaneous scopolamine butylbromide, compared with placebo, significantly reduced the occurrence of the death rattle.

Do you have any questions regarding Under My Microscope?

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Media Watch: A potpourri

The articles below are selected from recent issues of Barry R. Ashpole’s weekly report Media Watch.

What’s Wrong With Advance Care Planning?

JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION | Online – 8 October 2021 – Advance care planning (ACP) has emerged during the last 30 years as a potential response to the problem of low-value end-of-life (EoL) care. The assumption that ACP will result in goal-concordant EoL care led to widespread public initiatives promoting its use, physician reimbursement for ACP discussions, and use as a quality measure by the U.S. Centers for Medicare & Medicaid Services, commercial payers, and others. However, the scientific data do not support this assumption. ACP does not improve EoL care, nor does its documentation serve as a reliable and valid quality indicator of an EoL discussion... During the last 25 years, studies have evaluated ACP with various methods and across large groups of patients. Despite the intrinsic logic of ACP, the evidence suggests it does not have the desired effect. DOI: 10.1001/jama.2021.16430

Full text

[Review] Palliative and End-of-Life Care Service Models: To what extent are consumer perspectives considered?

HEALTHCARE | Online – 28 September 2021 – This article presents evidence found in a search of national and international literature for patient preferences concerning settings in which to receive palliative care (PC) and the appropriateness of different models of PC. The purpose was to inform end-of-life care (EoLC) policy and service development of the Western Australian Department of Health through a rapid review of the literature. It was found that consumer experience of PC is investigated poorly, and consumer contribution to service and policy design is limited and selective... Models of care do not make systematic use of the consumer data that are available to them, although an increasingly common theme is the need for integration of the various sources of care supporting dying people. The authors argue that models of care should take account of consumer experience not by incorporating generalised evidence but by co-creating services with local communities using a public health approach. DOI: 10.3390/healthcare9101286

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Access to Palliative Care Reimagined

FUTURE HEALTHCARE JOURNAL | Online – 23 September 2021 — Access to palliative care is commonly considered as solely a health services challenge rather than a community challenge. Successive healthcare reports continue to pose the question of access and its solution in terms that ask what a service can do rather than what an ally a service can become. However, the question is not what can we do for disadvantaged communities, but rather, what can we do together with them as fellow providers of palliative care. The first part of this article reviews the most common recommendations offered for increasing access to palliative care. The second part advocates an alternative way to address this challenge by employing the key practice methods of a new public health / health promotion approach to palliative care. DOI: /10.7861/fhj.2021-0040

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On the same topic

[Comment] Access to Palliative Care: The primacy of public health partnerships and community participation

New Public Health Approaches to Palliative Care, A Brave New Horizon Or An Impractical Ideal? An Integrative literature review with thematic synthesis.

Media Watch monitors the literature and the lay press on issues specific to the quality of end-of-life care. It is international in scope and distribution. View current and back issues here.

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