[The anesthetist's view on Jethro Tull's Aqualung]

Im Jahre 1971 veröffentlichte die britische Rockgruppe Jethro Tull ihr Meilensteinalbum Aqualung. Darauf ist ein Lied gleichen Titels zu hören, das die Geschichte eines Wohnungslosen namens „Aqualung“ erzählt, der einen kalten Tag auf einer Bank in einem Londoner Park verbringt. Es passiert nicht wirklich viel: Er schaut jungen Mädchen beim Spielen zu, bückt sich, um eine Zigarettenkippe aufzuheben, geht einen kurzen Weg zu einer öffentlichen Toilette, die Heilsarmee bietet ihm eine Tasse Tee an, er wird durch die junge Prostituierte „cross-eyed Mary“ erschreckt und flüchtet vor ihr und stirbt schließlich mit rasselnden letzten Atemzügen, die an Tiefseetauchergeräusche erinnern. Offensichtlich ist Aqualung schwer krank. Möglicherweise leidet er an einem Lungenödem, peripherer arterieller Verschlusskrankheit, posttraumatischer Belastungsstörung und vielleicht noch an weiteren der vielen, für Wohnungslose typischen Erkrankungen. Die Beschreibung seiner letzten Atemzüge mag den Anästhesisten an das Todesrasseln erinnern. Eine Möglichkeit, medizinisches Fachwissen an Ärzte zu vermitteln, besteht darin, Daten und Fakten über Erkrankungen mit Elementen der Popkultur zu verknüpfen. Dieser Essay möchte einen bis heute berühmten Rocksong als Vehikel nutzen, um Anästhesisten und Intensivmediziner für intensivmedizinisch relevante Erkrankungen von Wohnungslosen zu sensibilisieren und den Wissensstand zu verbessern.

When they stop drinking-examining end-of-life hydration practices and death rattle occurrence

PURPOSE

To characterize the practice of subcutaneous hydration provision in the Beer-Sheva home care hospice unit. We also explore the potential connection between the provision of subcutaneous hydration and the incidence of death rattle.

METHODS

This was a prospective observational study involving 120 hospice patients. During the 6 days before death, hospice staff recorded whether or not fluids were administered orally and/or subcutaneously; the duration, timing, and quantity of fluid administration; the incidence, timing, and duration of death rattle; and whether medications that can affect death rattle were given.

RESULT

Fifty-three percent of the patients received subcutaneous hydration. The mean daily volume administered in the hydration group was 434 ml. There was a significant association between the duration of treatment in the hospice unit and provision of subcutaneous hydration (mean of 51 days in hydration group vs. 31 days in non-hydration group, p = 0.03). Although not statistically significant, males were more likely to receive subcutaneous hydration than females (62% of males vs. 46% of females, p = 0.09). There was a higher incidence of death rattle in men compared to women (54.7% in men vs. 32.8% in women, p = 0.025). A statistically significant association between death rattle and the provision of subcutaneous hydration wasn't demonstrated.

CONCLUSION

The decision of whether to provide subcutaneous hydration is individualized taking into consideration the values of the patients and their families. The provision of 500 ml per day of subcutaneous saline during the last 6 days of life does not significantly increase the incidence of death rattle.

Care strategy for death rattle in terminally ill cancer patients and their family members: recommendations from a cross-sectional nationwide survey of bereaved family members' perceptions

CONTEXT

Bereaved family members witnessing a patient's death rattle often experience distress. However, the benefits of specific care measures aimed at decreasing death rattle-associated family distress have not yet been evaluated.

OBJECTIVES

To clarify death rattle-related emotional distress levels among family members and their perceptions of the need for death rattle care improvement and explore the factors influencing both these issues.

METHODS

A cross-sectional questionnaire survey of bereaved family members of cancer patients was conducted in 95 palliative care units in June 2007.

RESULTS

Six hundred sixty-three questionnaires were mailed out, and 390 (61%) responses were analyzed. Among these, 181 (46%) respondents experienced death rattle. Of these, 66% reported high distress levels and 53% perceived a strong need for improved death rattle care. Factors influencing high distress levels were the gender (female) of family members, unawareness about death rattle being a natural phenomenon, and their fear and distressing interpretations of death rattle. Factors influencing perceptions of a strong need for improved care were the gender (male) of family members, severity of death rattle, death rattle-associated discomfort to patients, family members' experiences of inadequate nursing care (e.g., repositioning) and insufficient consultation about suctioning, and their perception of uncomfortable smells.

CONCLUSION

To decrease family-perceived distress, medical staff should alleviate patient symptoms and suffering with a comprehensive care strategy, try to decrease uncomfortable smells, and communicate with family members to address distressing interpretations and fears.

Prevalence, impact, and treatment of death rattle: a systematic review

CONTEXT

Death rattle, or respiratory tract secretion in the dying patient, is a common and potentially distressing symptom in dying patients. Health care professionals often struggle with this symptom because of the uncertainty about management.

OBJECTIVES

To give an overview of the current evidence on the prevalence of death rattle in dying patients, its impact on patients, relatives, and professional caregivers, and the effectiveness of interventions.

METHODS

We systematically searched the databases PubMed, Embase, CINAHL, PsychINFO, and Web of Science. English-language articles containing original data on the prevalence or impact of death rattle or on the effects of interventions were included.

RESULTS

We identified 39 articles, of which 29 reported on the prevalence of death rattle, eight on its impact, and 11 on the effectiveness of interventions. There is a wide variation in reported prevalence rates (12%-92%; weighted mean, 35%). Death rattle leads to distress in both relatives and professional caregivers, but its impact on patients is unclear. Different medication regimens have been studied, that is, scopolamine, glycopyrronium, hyoscine butylbromide, atropine, and/or octreotide. Only one study used a placebo group. There is no evidence that the use of any antimuscarinic drug is superior to no treatment.

CONCLUSION

Death rattle is a rather common symptom in dying patients, but it is doubtful if patients suffer from this symptom. Current literature does not support the standard use of antimuscarinic drugs in the treatment of death rattle.