{"entity":{"id":"idea-upgrade-prophylactic-antimuscarinic-when-dying-recognised","kind":"idea","name":"An antimuscarinic started when dying is recognised, to prevent the death rattle rather than treat it","aka":[],"tldr":"Noisy breathing in the last days of life, often called the death rattle, distresses many families. Guidelines give a drug to dry the secretions only once the noise has started and is causing distress. In one Dutch trial, starting the drug as soon as dying was recognised halved how often the rattle appeared.","summary":"Current practice. NICE NG31 (2015) asks teams to reassure families, consider non-drug measures, and consider atropine, glycopyrronium or hyoscine only once noisy secretions are distressing the dying person; the Korean last-days guideline (2020) grades drug treatment C IIb. Neither recommends prevention.\n\nThe trial. SILENCE randomised 162 people in six Dutch hospices, at the point the dying phase was recognised, to subcutaneous scopolamine butylbromide 20 mg four times a day or placebo (157 analysed). A death rattle of grade 2 or more occurred in 13% against 27% (difference 14%, 95% CI 2% to 27%). Restlessness was 28% against 23%, dry mouth 10% against 15% and urinary retention 23% against 17% among those assessed. It is one trial, in hospices, of one drug.\n\nThe gap. No guideline read has adopted prophylaxis, and how often it is used has not been measured.","asOf":"2026-10-20","links":[{"label":"van Esch et al., Effect of Prophylactic Subcutaneous Scopolamine Butylbromide on Death Rattle in Patients at the End of Life: the SILENCE randomized clinical trial (JAMA 2021)","url":"https://doi.org/10.1001/jama.2021.14785"},{"label":"NICE guideline NG31, Care of dying adults in the last days of life: recommendations 1.5.29 to 1.5.34 (2015)","url":"https://www.nice.org.uk/guidance/ng31/chapter/Recommendations"},{"label":"Clinical Practice Guideline for Care in the Last Days of Life (Korean J Hosp Palliat Care 2020)","url":"https://doi.org/10.14475/kjhpc.2020.23.3.103"}],"tags":["protocol-upgrade","upgrade:promising","evidence:moderate"],"related":[],"cancers":[],"sections":["supportive-care"],"technologies":["syringe-drivers","palliative-care"],"targets":[],"drugs":[],"companies":[],"institutions":[],"pathways":[],"terms":["last-days-of-life-care"],"trials":[],"people":[],"bottlenecks":["b-palliative"],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"hypothesis":"Starting subcutaneous scopolamine butylbromide when the dying phase is recognised, outside hospices as well as in them, reduces the proportion of people who develop a distressing death rattle and family distress at the bedside, without a meaningful rise in restlessness or urinary retention.","rationale":"The drugs are cheap, already in anticipatory medicine boxes and given by the same route; the only change is timing. The one randomised trial is positive on its primary outcome, so the question is whether the effect holds in hospitals and at home and whether it matters to families.","test":"A pragmatic randomised or stepped-wedge trial across hospital wards and community palliative care of prophylactic against on-demand antimuscarinic, with death rattle grade, bereaved family distress and anticholinergic side effects as outcomes.","maturity":"early-clinical","actor":"clinic","cost":"small","horizonYears":3},"route":"/ideas/idea-upgrade-prophylactic-antimuscarinic-when-dying-recognised/","neighbours":{"section":[{"id":"supportive-care","kind":"section","name":"Supportive Care & Survivorship","route":"/fronts/supportive-care/"}],"technology":[{"id":"palliative-care","kind":"technology","name":"Early integrated palliative care","route":"/technologies/palliative-care/"},{"id":"syringe-drivers","kind":"technology","name":"Syringe pumps and subcutaneous syringe drivers","route":"/technologies/syringe-drivers/"}],"term":[{"id":"last-days-of-life-care","kind":"term","name":"Care of dying adults in the last days of life","route":"/terms/last-days-of-life-care/"}],"bottleneck":[{"id":"b-palliative","kind":"bottleneck","name":"Pain relief and palliative care are unavailable to most","route":"/bottlenecks/b-palliative/"}],"protocol":[{"id":"care-in-the-last-days-of-life","kind":"protocol","name":"Care in the last days of life: recognising dying, hydration, symptom control and anticipatory medicines","route":"/protocols/care-in-the-last-days-of-life/"}]}}