The death rattle

In this last few weeks I have had more patients die then ever before. Not for lack of care but more because it was in their best interest. And what I mean by that is that a) their quality of life was poor 2) their prognosis was incredibly poor and 3) the treatments caused more suffering than anything else. Sad as it may be in two cases the family made tis tremendously difficult decision for their loved one and care was withdrawn. For the third the pt own mind/ body made the decision we as providers and family were postponing, and he died peacefully.
It is unsettling as a physician to see these things take place, in all cases I knew the families had mad the right choice but no matter it was still difficult. I found myself avoiding going to these pts rooms as a means of avoiding further discussions of impending death. The palliative care service was/is amazing. I don't know how they deal with death at every consult.
So this is what I learned about helping someone die comfortably. First help the family make the decision, answer all of their questions regarding death and the process once you begin, the duration, etc. prepare them and prepare the nursing staff help them feel comfortable with the process as well. Attend to their spiritual needs, get sw early to help them with funeral arrangements. And finally the patient needs benzos for sedation, and quiver of anxiety in their face, typically midazolam because of its short half life and quick onset. Morphine has a unique ability to take away the feeling that one is gasping for breath. In studies of people put to exertion morphine made them feel more comfortable and not as short of breath, making them feel more at ease despite being dyspnic. The same applies do a pr that is is being extubated and will likely be short of breath without intubation. Therefore morphine is given to quell the patients feeling of being starved for breath. And the last need is for glycopyrolate. As I have get to witness I have been told when a person dies secretions develop in their lungs and makes a sort of rattling in their chest, called the "death rattle.". Glycopyrollate helps with these secretions and eliminated the rattle, making the family more at ease. Also all lines unnecessary beeping machines are removed and stopped. And that is it.