First of all, the cited study Shimuzu et al from 2014 took place in Japan. Secondly, the article has a lot of more information about perception of "death rattle" - as always, perceptions need to be seen and interpreted within cultural context. I think everybody would agree that Japanese culture is very different from USA culture - perhaps USA family perception is similar but one cannot just assume... I am a certified hospice and palliative nurse (CHPN) with experience in acute care and community care - I have taken care and consulted on many patients who are in the stage of actively dying. In addition, I am a member of a professional nursing organization dedicated to palliative and hospice care (HPNA). Anybody who takes the time to review some literature on this topic "death rattle" and professional recommendations will find that naso-pharyngeal sunctioning or "deep suctioning" is NOT recommended because it does not remove the pooled secretions that result in the rattling noise. It does lead to discomfort and can result in injury and even bleeding in patients while absolutely not doing anything for the rattling. It seems that nurses in ICUs have the hardest time to resist the urge to stick a suction catheter in - nurses on medical surgical floors who are more familiar with this natural phenomenon in the dying patient usually do not attempt. Since the rattling noise that one hears close to the throat comes from seecretions that pool (patients cannot swallow close to death) in that area there is actually a simple nursing action that removes the secretions, can be integrated while providing care, and is effective: You simply turn the patient fully onto the side until the head is the lowest point - take the pillow out - place a washcloth under and simply wait few minutes with patient in this position. Secretions run out because of gravity. After that, reposition in 30 degree side and place pillow under the head again. I often see that the head is overextended, which results in the mouth being wide open and it looks uncomfortable. Make sure you have enough pillows... Secondly nurses need to educate the family and each other that "rattling" is a normal phenomenon, which does not disturb the patient. Thirdly, there are randomized controled studies about the effectiveness of medication to dry out secretions and other studies - some studies concluded that medication is not more effective compared to placebos. Current practice is that patients receive scopolamin patches or / and levsin to help with drying out secretions, sometimes patients get a dose of lasix if they are fluid overloaded and the rattling is further down / pulmonary edema. I also usually recommend to make sure patients do not receive iv fluids while they are dying because the body can't handle it and it seems to result in more "rattling". Please fellow nurses - do not stick a suction catheter deep down the throat or through the nose - Yankauer is fine for in the mouth cavity. Instead, position onto the side as described and wait for secretion to run out. If patients build a lot of secretions you might have to do that more regularly but you should repositioning anyways and can integrate it. I have done this numerous times and still do when I see a rattling patient who is dying in acute care. Gravity is your friend....And the best thing is that does not harm the patient. If the patient appears to be close to death (mottling etc.) make sure the family understands that death is imminent. Families are usually relieved when I educate them about the rattling and repositioning. Yes - the rattling noise causes distress in families and staff that is not educated. But suctioning does not help and is usually more for the nurse's own comfort. Repositioning takes more time and 2 people - so I can see why suctioning seems more appealing - but it usually does not help and can make it worse. I have seen patient bleed significantly after somebody sunctioning through the nose or "deep suctioning" while patient is dying - that is even worse than rattling. There are many articles but I am only citing one here: Jancin, Bruce. "Simple measures for dying patients can limit secretions, death rattle." Internal Medicine News, 1 Aug. 2007, p. 16. Academic OneFile, Off-Campus Login. Accessed 19 Sept. 2018.