Comparison of management of noisy breathing at the end of life in two Hospices in the UK

Background Excessive respiratory secretions are common at the end of life. A Cochrane review concluded that there was no current evidence of effectiveness of current interventions but it is a symptom that relatives find distressing in end of life care. Therefore clinicians need to balance the available evidence with the distress remarked on by relatives. Aim To compare audits on the management of ‘death rattle’ in two hospices against national guidelines. Methodology Retrospective, case note review of inpatients who died over a 5 month period in 2010 (Unit 1) and in 2011 (Unit 2). Results Unit 1: 73 patients: 66 had antisecretory medication prescribed. Twenty-four patients needed the medication. 27/66 had incorrect doses prescribed. 21/24 had response assessed/documented. 18/24 patients documented benefit from the antisecretory drug. Non-Pharmacological measures, 2/24 patients had evidence of re-positioning only with no documentation of communication with the family (0/24). 20/24 patients died within 48 h of the first dose of antisecretory medication. Results Unit 2: 72 patients: 65 had antisecretory medication prescribed. 36 patients needed the medication. 16/65 had incorrect doses prescribed.29/36 response assessed/documented. 24/29 patients had documented benefit from the antisecretory drug. Non-Pharmacological measures, 3/36 patients had evidence of re-positioning with 4/36 documentation of communication with the family. 22/36 patients died within 48 h of the first dose of antisecretory medication. Conclusion Patterns of antisecretory medication appears very similar pattern in both hospices. In the majority of cases, documentation supported adherence to the national guidelines. Of note is the considerable dose variation in the drugs prescribed. This has been highlighted as an education and training issue. The supporting documentation to evidence the use of non-pharmacological measures but also in communicating with the relatives about the ‘death rattle’ needs further work.