Let’s discuss a difficult topic. One that no one likes. . . .


The death rattle . . .
Terminal congestion . . .
Excessive oral secretions . . .
However you would like to refer to it. It’s not pretty, I know.


It is one of the hardest things to watch and listen to at end of life, even as a nurse. While standing at the bedsides of many patients, I often found myself clearing my own throat and swallowing as if that would some how help them. Of course it doesn’t.


But what does is proper education.


What is end of life congestion?

Terminal congestion, the death rattle, is a build up of fluids in the back of the throat and airway during the last few days to hours of life.


It can be heard without a stethoscope and can sound almost like bubbles popping as the patient breathes. Usually, it is not as uncomfortable for the patient as we would imagine it is, but as a caregiver it is definitely hard to listen to and watch.
There are times where the congestion is so significant and patients may have brownish or tan mucous coming from their mouth, or even their nose. Generally speaking, at this point, the patient is unresponsive and they do not have the strength to cough or clear their throat.


What causes it?

Many factors can contribute to end of life congestion. When a patient has a terminal condition that involves the lungs or heart, like lung cancer or congestive heart failure, this is not an uncommon finding, but it can also be present in a variety of other conditions.
This can also be seen in patients who are being given food or fluids when they are unable to safely swallow.


What can you do to help?

The first thing most people think of is to put the head of the bed as high as the patient can tolerate or get out a suction machine.
WAIT! Don’t do it just yet! Let’s talk about this!



After my 18 years of experience, I have learned that when you put the head of the bed up, the patient is on their back, and they do not have the strength to clear the secretions on their own, the fluid has no where to go.
It’s just going to sit there and continue to bubble, pop, and froth in the back of their throat until it’s either removed or able to drain.

By putting the head of the bed all the way down and turning the patient FAR onto their side, this will assist the fluid to come up and out rather than sitting in the back of the throat.

Use pillows to assist with the positioning.

Put a pillow in front of them and lean their upper body into it. Use a pillow behind their back to help with propping them there. Make sure to put a small hand towel on the pillow mostly in front of their mouth for whatever secretions may come up and out.

There are of course people who cannot tolerate being flat or being on their side, but the majority of people can. Do your best.



Oral care:

Use oral swabs, slightly moistened, to assist in cleaning out their mouth as needed. If they bite down on the swab, leave it there for a moment until they settle in again and their jaw relaxes, and then remove it. Do not pull it through their clenched mouth.
Also, please wash their face if it drips down. We would want the same done for us.


It may be appropriate at times to get an oral suctioning machine, but this is only to clear what is in their mouth. Most times, suction is not necessary.


When you introduce deep suctioning, which is taking a suction catheter and sliding it down into their upper airway/throat, this can cause the body to try to protect itself and produce even more secretions. For this reason, it is generally not advised because it can make it worse, not better.




There are a few medications that can assist in drying up the secretions.
If the above measures have not been effective in reducing secretions, your hospice care provider can prescribe the medications. Keep in mind, the medications are helpful, but they do not work immediately and are not miracle drugs. If the congestion is not too bad, it may clear it up. If the congestion is pretty copious, it may help to reduce it but they need to be given consistently along with the natural measures described here.



Positioning next time:

Imagine taking a container and filling it with a stickier type fluid, then laying it on its side. All that fluid will settle towards the bottom. When you flip it over, it is going to take some time for that fluid to move and settle onto the other side.


This is basically the same concept.
When you go to reposition your loved one again, this fluid is going to move, it may get in the way temporarily and take some time to settle to the other side. During this positioning you may notice that the congestion sounds worse. This may only last a few minutes and generally improves once it settles.
However, if they can not tolerate the move or if they start turning colors or having serious breathing changes, I would suggest putting them back where they were and focus on smaller movements or body adjustments instead to try to prevent skin breakdown.
It can be scary at times. Do your best.



This symptom at end of life can be distressing, but with proper education and helpful techniques it can be better managed.

I hope you found this helpful and if you have questions, please reach out to me!