Understanding Anticholinergic Use in Palliative Care

The use of anticholinergic agents to manage terminal secretions, often referred to as the 'death rattle', is a complex aspect of end-of-life care. These medications are commonly employed in hospice and palliative settings to alleviate distressing sounds associated with secretions, yet their effectiveness in enhancing patient comfort remains debatable.

Expert Insights from Leading Pharmacists

In an insightful interview, Pharmacy Times spoke with Diana Violanti, PharmD, and Pamela S. Moore, PharmD, two distinguished clinical pharmacist specialists in palliative care, who discussed the critical considerations when it comes to selecting anticholinergic medications, timing of their use, and the delicate balance between benefits and risks in this sensitive patient population.

The Right Anticholinergic for the Right Patient

Dr. Violanti pointed out that effective symptom management often hinges not on clinical trials but on practical considerations. For hospitalized patients, the choice of medication typically starts with understanding the patient's goals—be it transitioning to hospice care or continuing in a hospital setting. She favors glycopyrrolate for its lower risk of causing delirium, particularly for those who can still communicate.

Dr. Moore echoed this sentiment, noting that for home-bound patients, decisions can be more intricate. While she commonly prescribes glycopyrrolate in tablet form for patients not yet in hospice, she turns to sublingual hyoscyamine for those nearing the end of life—an easier option for caregivers that still minimizes distress.

Timing is Everything: When to Start Treatment

According to Dr. Moore, the optimal time to initiate anticholinergic therapy is as soon as the 'death rattle' is observed, especially if it's distressing to caregivers. While these medications don't remove existing secretions, they can help reduce subsequent production. She advocates a proactive approach, suggesting that preventive measures could be beneficial for patients at high risk as they enter the dying phase.

The Evidence Landscape: Efficacy and Concerns

Despite their common use, the evidence supporting the efficacy of anticholinergics in improving comfort at the end of life is mixed. Many in the field remain hesitative—arguing that not every patient experiences distress from terminal secretions, and unnecessary medication could carry unwanted side effects. Others contend that it’s impossible to fully gauge a patient's suffering, especially in those with conditions like Parkinson's or ALS. The ongoing research attempts to clarify the role of these medications in patient care.

Weighing the Risks: Adverse Effects to Consider

Both experts expressed concern regarding the potential adverse effects of anticholinergics, particularly their impact on sedation and cognition. Dr. Violanti emphasized the importance of minimizing these risks, particularly as end-of-life approaches. While glycopyrrolate is more expensive, its benefits may outweigh the costs due to its lower central nervous system side effects.

Dr. Moore raised a valid point that treating patients who live longer may encounter significant side effects like xerostomia and constipation, which necessitate careful monitoring and management.

Guiding Caregivers and Providers

As pharmacists, it’s essential to counsel caregivers and healthcare providers about the goals of anticholinergic use in managing terminal secretions. Open communication about the potential benefits, limitations, and side effects of these medications will help ensure that end-of-life care remains compassionate and tailored to the individual patient's needs.