Dysphagia & Managing Oral Secretions

As residents near the end of life, one of the signs most often encountered is the loss of the ability to swallow.  This article will look at how to manage this problem.

How It Begins

It often begins before the resident is actively dying with dysphagia, or trouble swallowing, usually caused by weakness and poor neurologic function.  The resident may cough, clear his throat, or sputter while eating or drinking.  Thickening fluids may help to start with, since thicker liquids are less likely to pass into the trachea which can lead to aspiration pneumonia.

Preventing Pneumonia

Later, even making fluids thicker is not enough.  The gag reflex and reflexive clearing of the throat decline.  It is probably time to stop feeding the resident at this point to prevent pneumonia.  Usually this comes at the same time as loss of appetite; the resident does not experience hunger any longer and though feedings stop, it does not cause distress.  It is important to take the time to explain this process to the family.

Noisy Breathing

As the resident becomes less aware and it is clear that death is nearing, those at the bedside may hear a rattling, gurgling, crackling noise with each breath.  This is caused by the build-up of secretions in the throat; the resident cannot swallow them the way most people normally do.  This noise is sometimes called a “death rattle,” (although this term should never be used around families and caregivers).

Medications

These noisy respirations can be very disturbing to family and caregivers.  It may be helpful to try to dry the secretions by using an anticholinergic medication such as atropine or scopolamine.

 
Atropine drops (normally used in the eye) may be ordered for administration under the tongue and scopolamine patches (often used to prevent motion sickness) can be applied behind the ear.  Both seem to work equally as well, and neither affects survival time.  These drugs can be used in the unconscious dying patient before noisy breathing begins to prevent it from happening.

Non-Drug Treatments

Repositioning the resident can help to clear the secretions.  Turning the resident far to one side and then the other (to a semi-prone position) may allow the secretions to drain through the mouth (be sure to have a towel ready for drainage).  Raising the foot of the bed very briefly while on the side may also help, but never leave the resident in this position for more than two or three minutes at the most.

Suctioning

Oropharyngeal suctioning is not recommended.  Suctioning can be very distressing to the resident and family, and it is often ineffective since the secretions are usually beyond the reach of the suction catheter.  Suctioning can also stimulate more secretions.