What is the recommended dosage of atropine (anticholinergic) ophthalmic solution for a hospice patient, likely an older adult with a terminal illness and potential comorbidities such as dementia or cancer, to increase secretions?

Atropine Ophthalmic Solution for Excessive Secretions in Hospice Patients

For hospice patients with excessive respiratory secretions (death rattle), administer atropine 1% ophthalmic solution 1-2 drops sublingually every 4 hours as needed. 1

Dosing Algorithm

Standard Dosing

• Administer 1-2 drops of atropine 1% ophthalmic solution sublingually every 4 hours as needed for reduction of excessive secretions 1
• This dosing is specifically recommended by the National Comprehensive Cancer Network (NCCN) for patients with life expectancy measured in years, months, or weeks 1

Alternative Anticholinergic Options (if atropine unavailable)

• Scopolamine 0.4 mg subcutaneously every 4 hours as needed, or 1.5 mg patches (1-3 patches every 3 days) 1
• Glycopyrrolate 0.2-0.4 mg IV or subcutaneously every 4 hours as needed 1
• Hyoscyamine 0.125 mg PO/sublingual every 4 hours as needed 1

Clinical Evidence Supporting This Approach

Efficacy Data

• A retrospective study of 22 hospice patients treated with sublingual atropine 1% ophthalmic drops demonstrated that 19 patients (86%) had documented reduction or resolution of terminal respiratory secretions 2
• The sublingual route obviates the need for subcutaneous infusions and avoids additional somnolence that may occur with parenteral administration 3

Route of Administration Rationale

• The sublingual route is specifically chosen because it provides effective absorption while avoiding the need for injections in dying patients 2, 3
• This off-label use of ophthalmic drops is widely accepted in hospice and palliative care practice 1

Critical Safety Considerations

Anticholinergic Burden Warning

• Be cautious in patients with dementia, as atropine adds to anticholinergic burden and may increase fatigue and confusion 1
• In a study of 1,283 hospice patients with dementia, atropine was the second most commonly prescribed anticholinergic drug (32.6% of those receiving anticholinergics), contributing to cognitive impairment risk 4
• The American Heart Association specifically warns that using atropine for excessive secretions may add anticholinergic burden and increase fatigue 1

Cardiovascular Considerations

• Monitor for tachycardia, which could worsen ischemia in patients with underlying cardiac disease 1
• However, problematic cardiac or central nervous system symptoms were not documented in the hospice study of 22 patients 2

Common Pitfalls to Avoid

Medication Error Risk

• Never administer atropine ophthalmic drops into the eyes when prescribed for secretion management 5
• A case report documented severe vision blurring when hospice-prescribed sublingual atropine drops were mistakenly administered ophthalmically during hospitalization 5
• Clearly label the prescription "FOR SUBLINGUAL USE ONLY" and educate all caregivers about the correct route 5

Documentation Requirements

• Ensure medication orders specify "sublingual" route explicitly to prevent administration errors during care transitions 5
• When patients transfer between care settings, verify that receiving providers understand this off-label use 5

Timing and Goals of Care Alignment

When to Initiate

• Atropine for secretions is appropriate across all life expectancies in hospice patients (years, months, weeks to days) according to NCCN guidelines 1
• The primary goal is comfort and reduction of distressing respiratory sounds for both patient and family 1

Reassessment

• Monitor for adequate symptom control and reduction of patient/family distress 1
• If secretions persist despite atropine, consider switching to or adding scopolamine or glycopyrrolate 1