Whether to Suction, and Why You Usually Don't

Should you suction a dying person's mouth?

In almost every case, no — and no home suction machine is needed. As a person dies, a little saliva and mucus collects near the back of the throat, because the reflexes that normally swallow and cough it away have grown too weak to work. This is the death rattle, and the evidence that treating it aggressively does any good is weak 1Ref 1Lokker ME, van Zuylen L, van der Rijt CCD, van der Heide A (2014).Prevalence, Impact, and Treatment of Death Rattle: A Systematic Review.Terminal respiratory secretions (the death rattle) are pooled fluid the dying person can no longer clear; the sound distresses families far more than the largely unaware patient, and the evidence for drying medicines is weak.. Deep suctioning reaches only the front of the mouth, and the fluid returns within minutes.

The instinct to clear it out is powerful, and it comes from love. But suctioning at end of life usually works against comfort rather than for it: a catheter passed toward the throat can set off gagging and coughing in someone too frail to tolerate it, and because the secretions sit lower than the tube can reach, the sound comes back almost as soon as you stop. Wiping pooled saliva from the very front of the mouth with a soft swab is gentle and fine. Passing anything deeper is the part hospice teams generally leave alone.

What causes the rattling sound?

The sound is air moving over a small pool of saliva and mucus that has gathered in the throat and upper airway. By this stage most people are deeply unconscious and no longer swallow or clear their throat the way they did, so the fluid simply sits there and each breath passes through it. It tends to appear in the final phase of dying, and it is one of the changes in breathing that hospice teams prepare families to expect 2Ref 2National Institute on Aging (NIH) (2022).Providing Care and Comfort at the End of Life.Changes in breathing near the end of life are expected, and comfort is provided through family-facing measures such as repositioning and mouth care..

It helps to name what it is not. It is not the person choking, and it is not the feeling of being unable to breathe. The airway is open; the fluid is pooled, not blocking it. The rattle can rise and fall with each breath and change from one hour to the next. None of that variation means something has gone wrong — it is the ordinary sound of a body that no longer has the strength to clear its own throat 1Ref 1Lokker ME, van Zuylen L, van der Rijt CCD, van der Heide A (2014).Prevalence, Impact, and Treatment of Death Rattle: A Systematic Review.Terminal respiratory secretions (the death rattle) are pooled fluid the dying person can no longer clear; the sound distresses families far more than the largely unaware patient, and the evidence for drying medicines is weak..

Is it distressing the person, or the people listening?

Far more often, the people listening. Studies of the death rattle find that it causes real distress in families and others at the bedside, while the dying person — usually deep in unconsciousness by the time it starts — shows no signs of distress 1Ref 1Lokker ME, van Zuylen L, van der Rijt CCD, van der Heide A (2014).Prevalence, Impact, and Treatment of Death Rattle: A Systematic Review.Terminal respiratory secretions (the death rattle) are pooled fluid the dying person can no longer clear; the sound distresses families far more than the largely unaware patient, and the evidence for drying medicines is weak.. We cannot know for certain what an unconscious person experiences. But the weight of evidence and bedside experience is that the rattle is a sound the room hears, not a struggle the person is having.

This is the reassurance families most need and least believe. Whether you are caring for a dying spouse, a parent, or a friend, the fear that they are drowning in their own secretions is one of the most common at this bedside, and it is understandable — the sound is awful. Holding onto what the person's face and body are telling you helps: a slack, peaceful expression, no grimacing, no clawing at the air, is a more reliable guide to their comfort than the noise itself.

What helps more than suctioning

Small, physical measures do more than any machine. The single most effective one is position: turning the person gently onto their side, or slightly toward their front, so gravity can drain the pooled fluid toward the cheek where it can be wiped away. Raising the head of the bed a little often helps too. These are the comfort measures hospice teams teach, and they can begin before any call is made 2Ref 2National Institute on Aging (NIH) (2022).Providing Care and Comfort at the End of Life.Changes in breathing near the end of life are expected, and comfort is provided through family-facing measures such as repositioning and mouth care..

Alongside position, a few things ease the picture:

• Turn and re-settle. Rolling the person onto one side, then later the other, is the core of terminal secretions positioning — it moves the fluid to where it can drain rather than pool.
• Mouth care. A soft, moist swab wiped around the mouth clears what has gathered at the front, and dry mouth care with swabs and a little lip balm keeps the lips and tongue comfortable.
• Ease the fluid coming in. Less fluid overall usually means fewer secretions, which is why the hospice may raise the question of hydration.
• Calm the room. Lower the lights, soften your voices, and let a fan move a little air. Much of good death rattle care is making the room gentler for everyone in it, the person included.

Should fluids stop, and when does the hospice add a medicine?

These are the two levers beyond position and mouth care, and both belong to a conversation with the hospice rather than a decision made alone at night. Artificial hydration — fluids given by vein or through a tube — generally does not add comfort for someone who is dying 3Ref 3Peer-reviewed article (see publication) (2006).Artificial Nutrition and Hydration at the End of Life: Ethics and Evidence.Artificial nutrition and hydration near the end of life generally do not prolong life or improve comfort., and fluid the body can no longer process tends to settle in the chest and throat, feeding the very secretions you are trying to ease.

The hospice may also add a drying medicine — an anticholinergic such as glycopyrrolate or scopolamine — to slow how much saliva is made. It is worth knowing what these do and do not do. The evidence that they outperform simple positioning is weak 1Ref 1Lokker ME, van Zuylen L, van der Rijt CCD, van der Heide A (2014).Prevalence, Impact, and Treatment of Death Rattle: A Systematic Review.Terminal respiratory secretions (the death rattle) are pooled fluid the dying person can no longer clear; the sound distresses families far more than the largely unaware patient, and the evidence for drying medicines is weak.; they work better when started early than once secretions have built, and they cannot clear fluid that has already pooled. They can also bring side effects, such as a drier mouth or more confusion. If the hospice sends one home in the comfort kit, it arrives with a label written for this person — the amount and timing on that label, and the nurse on the phone, are the instruction. This page is not, and no dose belongs on a screen.

When to call the hospice nurse

The threshold is low, and the hospice line is answered around the clock — a fact many families do not know. A noisy breath in a person who looks peaceful is not cause to call; it is expected. What changes that is a sign the person is distressed rather than simply loud, or a sign the sound is coming from something other than ordinary secretions. Hospice is team-based care that supports the family through these hours 4Ref 4MedlinePlus, U.S. National Library of Medicine (2024).Hospice Care.Hospice is team-based, comfort-focused end-of-life care that supports the family..

Worth a call now rather than in the morning:

• The person looks distressed by the breathing itself — struggling, gasping, frightened, or grimacing — rather than resting through it.
• The secretions turn thick, colored, or foul-smelling, or arrive with a fever, which can point to a chest infection rather than ordinary terminal secretions.
• The noisy breathing comes alongside new restlessness or agitation — the plucking at bedclothes and stirring of terminal restlessness — which has its own comfort measures and is worth its own call.
• New end-of-life confusion appears, or the person stops settling, along with the change in breathing.
• You are frightened, or simply unsure what you are seeing. That is reason enough. Families are usually right that something has shifted, and no one at the hospice thinks less of the call.