I've been a hospice Nurse for over 20 years,worked in at least 3 different agency's. Where I work now has a "unwritten" order(by the Medical Director) to place one very,very long pressure on the bottle q 1! Now one of the Nurses on the dayshift is in the mist of a civil suit that she "hasten a death" by giving 2000n/g of atropine. ( 2000n/g = 0.002mg.)OF COURSE she was only trying to stop the pt. from drowning! Which ALOT of atropine DOES DO!! Cancer web site says 0.4MG Q 15 min,then if NO help IV scapalmine!! Needless to say Atropine is the unsung hero when pts are DROWNING,but EVERY HOSPICE seems to use it in their own way! I'd love some feedback about this subject.Has anyone else ran into this kind of "trouble" by family members? Thank you to anyone that can shed some light on this
We have what we refer to as Comfort Orders which the primary MD signs on admission to Hospice and we add meds as needed but have to fax a memo to the doc notifying him/her that we have started this med. Our Atropine order is for 2-4 drops every 4 hrs prn secretions and we start early in the process. We developed this in conjunction with the Pharmacist and Medical Director. I have also eone 2drops every 2 hrs prn and if I see that it is not being given to my inpatients I will get it ordered as a scheduled med instead of prn. That order for a squeeze every 1 hr is not going to fly by TJC for us, they want us to be very specific. I cannot imagine a lawsuit over Atropine drops, I feel for the people involved.
Our standing orders for Atropine are 1-2gtts, Q3 hr prn. A nurse has to initiate it, rather than just have the families start it.
I agree with shrinky that starting early helps a lot.
I'm not shy about asking for increased dose/frequency, (or Scop patches) but I'm not sure I'd be comfortable just squeezing................the dosage is going to be very different depending on the person doing the squeezing, how strong their hands are.......how bad a shift they've been having.
We too work with standing orders out of our "emergency kit" 4 gtts q 4 hrs prn
however, I prefer not to use Atropine if the pt is already tachy; are your patients really drowning or is it just terminal secretions which sound a lot worse then they are and can often be minimized with a side lying position?
a second scope patch if there is an order, which of course is never there when we really need it; but hey we do what we can to minimize the discomforts of dying!
Our standing orders when a patient is admitted to either Acute Hospice, Inpatient Hospice (Respite), or End of Life Cares are: Atropine 1% 1-2 gtts every 1 hour prn. We try to get a scopolamine patch on these patients as soon as they start getting more secretions...then we move to the Atropine. However, with our End of Life patients, we don't always have the time to let the scopolamine work, so we end up using Atropine gtts and repositioning techniques to make the dying process more comfortable and peaceful for the patient.
Wow, what a sticky situation. Atropine is a standing order for us as well...The scope patches should be standing order too in my humble opinion. I have not been a hospice nurse quite a year yet, so you guys have more experience than me, but the amount of atropine that I have given, I have not seen it work 100% effectively. The increased pulmonary secretions is just part of the dying process. We educate the family when the gurgling mortifies them. Suctioning doesn't help up to a certain point...but sometimes it makes the family feel better.
Thanks everyone for your reply's. I'm still not understanding why the Cancer.org gives.4mg q15 min. SQ.&If not working,THEN scopolamine I.V!!! and every hospice Nurse that answered this says their order's are about 1-2 drops q1 prn!! Which I know with 20+ years as a Hospice R.N. most of the time doesn't work! As you all can Imagine all of our Hospice Nurses are upset and trying to "get" to a standard order! Our Medical Director is now not standing by what she said! We all know That what this Day Nurse is going through could have been one of us! THANKS for ANY input!!!
The hospice I currently work for has standing orders for Atropine 1%, 4 gtts Q4 hr SL prn secretions...another hospice allowed same #gtts Q2 hr prn. we also have standing orders for either scopolamine transdermal or levsin if the atropine is not working well. I agree that position is helpful in controlling this troubling symptom. Make sure that you educate the family as well as possible as the noise is often more distressing for them than the symptom may be for the patient.
Standing orders for managing these common symptoms of the dying process should be in place for your hospice, if they are not you can get some support from your national and regional hospice and palliative care orgs to help your agency come in line with the standards of care.