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Death Rattle — SCE Medical Oncology MCQ

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HardSupportive & Palliative OncologyDeath RattleSCE Medical Oncology

An unconscious patient in the last hours of life has distressing noisy upper-airway secretions despite repositioning and review of assisted fluids. Which first-line Scottish palliative-care prescription is correctly written?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Hyoscine butylbromide 20 mg subcutaneously up to hourly as required, maximum 120 mg in 24 hours

Explanation lettering: C = shown as A · A = shown as B · E = shown as C · B = shown as E

D is correct. Scottish guidance uses hyoscine butylbromide 20 mg subcutaneously up to hourly as required, with a 120 mg maximum over 24 hours, after non-drug measures and avoidance of fluid overload. Glycopyrronium is measured in micrograms, not 20 mg, making A unsafe. Hyoscine hydrobromide is also microgram-dosed and more centrally sedating, so B is unsafe. C is a gross atropine overdose. E confuses the microgram scale used for glycopyrronium with hyoscine butylbromide. Antimuscarinics reduce new secretion formation rather than removing pooled secretions, and benefit and adverse effects require review.

Reference: Scottish Palliative Care Guidelines: care in the last days of life: https://www.rightdecisions.scot.nhs.uk/scottish-palliative-care-guidelines/last-days-of-life/care-in-the-last-days-of-life/