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and congratulate the authors on completing this work in a group notoriously hard to study. Although the outcomes of the study at face value support the regular use of anticholinergics to reduce the phenomena of noisy secretions, we believe the routine use of medications is not supported within the available evidence.
One of the most important findings of this paper is that not all the patients in the usual care arm developed noisy respirations. This was noted by the authors, and we raise it again as this means it is highly likely that a proportion of patients in the study's intervention arm received medications unnecessarily and, as a result, were exposed to unwarranted harms. Although it is impossible to understand how dying patients experience the unpleasant side effects of anticholinergic medications, data from the frail elderly suggest that their experiences with these medications may be unpleasant.
In addition, the authors correctly pointed out that there are high-level systemic review data that outline that, to date, the only real evidence to manage secretions lies with education and support to family members.
Our own clinical practice supports the benefits of talking with families and supporting nursing staff. As part of our role in providing consultative palliative care within the inpatient setting in a tertiary referral teaching hospital, we have recently introduced an approach to caring for the dying. Included in this package is support and education to the nursing staff that outlines the fact that not all patients will develop noisy breathing but if they do, this is likely to be more distressing to families and staff. We routinely use the analogy of the snoring where the snorer is not usually bothered but those around them are. In the 12-month that this project has been running, as illustrated in Figure 1 below, the prescription of glycopyrrolate has declined. Although glycopyrrolate is commonly used in the peroperative phase in operating theatres, it is also one of the most commonly recommended medications to address terminal secretions in Australia.
There is no doubt that noisy secretions at the end of life are sometimes perceived as very distressing to all those involved with the care of dying patients and further work is required. However, this work needs to focus on objectively identifying which patients are most at risk and once this is clearer, identifying evidence-based approaches to minimizing harm for all those involved: patients, their families, and health professionals.
Hyoscine butylbromide for the management of death rattle: sooner rather than later.