A patient has been receiving palliative care for the past several weeks in light of her worsening condition after a series of strokes. The caregiver has rung the call bell, stating that the patient 'stops breathing for a while, then breathes fast and hard, and then stops again.' You recognize that the patient is experiencing

• A. Apnea
• B. Bradypnea
• C. Death rattle
• D. Cheyne-Stokes respirations

Answer: (D)

Cheyne-Stokes respirations are a cyclical breathing pattern seen in advanced illness, where periods of apnea alternate with progressively deeper and faster breaths, followed by another apnea. The caregiver’s description—breathing stops for a while, then a burst of fast, hard breaths, then a pause again—fits this pattern exactly. It results from altered brainstem control of respiration and sensitivity to carbon dioxide, common after strokes or in the dying process.

This is not death rattle, which is noisy breathing from secretions in the airway; nor is it simple apnea alone, which would be a complete and ongoing cessation without the regular waxing and waning. It’s also not bradypnea, which is just slower-than-normal breathing without the cyclical ups and downs.