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

SPS commentary:

A related editorial discusses this research.  It states that this new trial provides the most rigorous available evidence that prophylactic subcutaneous scopolamine butylbromide is effective in reducing noisy breathing for dying patients. These data support the clinical approach of prophylactic anticholinergic medications, with the goal of reducing upper airway secretions before they form. Investigators employed a systematic approach to patient monitoring, and the absence of adverse effects associated with anticholinergic medications suggests the risks associated with this intervention were minimal. The authors note the primary controversy of the clinical question addressed by this study is that many clinicians question whether the death rattle should be treated. One argument is that there is no evidence to suggest this sign is distressing to a patient, and interventions may be costly and burdensome. One counterargument is to embrace humility and acknowledge that the internal experience of the dying, nonverbal patient cannot be fully known, but when in doubt regarding comfort, it is best to try treatment. Another reason to consider treatment for a death rattle is that the patient’s noisy respiration can have negative effects on family members and other observers.