[Death rattle or a silent death? Study gives rise to further reflections on a good death]. / Doodsreutel of een stille dood?

Death rattle, noisy breathing, is a frequent symptom in terminally ill patients for which (non)pharmacological treatment can be indicated. Although it remains unclear whether patients really experience suffering, family members may interpret this as a distressing sign of discomfort. Careful family communication remains pivotal. The SILENCE-study investigated the effectiveness of prophylactic use of scopolamine butylbromide to prevent death rattle. A double blinded randomized clinical trial in hospice patients was performed. Results were that patients in the intervention group had a significant lower prevalence of death rattle compared to the control group. The study applied innovative ways for performing a complex intervention study in palliative patients. Further reflection however is needed whether such preventive medication use may increase medicalization at the end of life. In this way, the Silence study gives rise for a broader reflection about what constitutes a good death and how society can take care of this.

Inappropriateness of using opioids for end-stage palliative sedation: a Dutch study.

To be able to distinguish end-stage palliative sedation from euthanasia without having to refer to intentions that are difficult to verify, physicians must be able to manage palliative sedation appropriately (i.e., see that death is not hastened as a result of disproportionate medication). In the present study, we assessed whether or not this requirement is met in the Netherlands. We sent a retrospective questionnaire to 1,464 medical specialists, general practitioners, and nursing home physicians in the Netherlands. Furthermore, we held two sets of 20 and 22 semi-structured in-depth interviews with general practitioners, internists, lung specialists, and nursing home physicians. Although most guidelines discourage the administration of opioids alone for purposes of palliative sedation, opioids alone were administered for 22% of all the patients reported upon. Those physicians who were more experienced, general practitioners, and physicians who had consulted a palliative care expert administered only opioids significantly less often than the other physicians. The interviewees reported difficulties in assessing the appropriateness of medication, feeling uncertain about the pharmacokinetics of drugs used in moribund patients. Given that no more than 2% of the respondents perceived palliative sedation to be used as a form of euthanasia and that the use of opioids alone was not associated with shorter survival rates, the inappropriate use of opioids can only be attributed to a lack of knowledge or skill and/or a tradition of alleviating refractory dyspnoea with the use of opioids and not as an intentional means of hastening death.