Antimicrobials at the End of Life
An Opportunity to Improve Palliative Care and Infection Management

JAMA. Published online October 01, 2015. doi:10.1001/jama.2015.

Patients in the final stage of an advanced illness often face challenging decisions about the direction of their overall medical care and treatment of specific complications that occur as the end of life approaches. Infections and febrile episodes are among the most common acute complications experienced by terminally ill patients.

Close to 90% of hospitalized patients with advanced cancer receive antimicrobials during the week prior to death, and 42% of nursing home residents with advanced dementia are prescribed antimicrobials during the last 2 weeks of life.
Approximately one-quarter of hospice recipients, for whom the intended goal of care is comfort, receive antimicrobials during the final weeks of life.
Research suggests that antimicrobials are commonly prescribed to dying patients in the absence of adequate clinical symptoms to support a bacterial infection.
How decisions for suspected infections are made in these patients warrants increased scrutiny by clinicians, patients, and family members.

RISKS AND BENEFITS
Although antimicrobial use may be viewed as relatively less burdensome than other potentially life-prolonging interventions (e.g., intubation, dialysis), risks of this therapy are not trivial, especially among frail patients with advanced disease.
Adverse outcomes of antimicrobial administration include drug reactions, drug-drug interactions, and Clostridium difficile infection.
Moreover, the evaluation (bladder catheterization, chest radiographs, blood draws) and treatment (intravenous lines) of suspected infections can contribute considerable burden in terminally ill patients, particularly when hospitalization is involved.
Antimicrobial exposure is the most important factor associated with the acquisition of multidrug-resistant organisms among patients at the end of life and is an increasing public health concern across care settings.

Two potential benefits of antimicrobials, prolonged survival and symptom relief, may motivate physicians to prescribe these drugs when treating terminally ill patients. No randomized trials have been conducted examining these outcomes in this population.

A systematic review included 8 observational studies that had measured symptoms following antimicrobial therapy among patients receiving hospice and palliative care. None of these studies, which were published between 2002 and 2008, had comparison groups of untreated patients, and their methodological heterogeneity and contrasting findings further limited any conclusions about whether antimicrobials provide symptom relief for patients at the end of life.

A subsequent prospective study in 2010, reported greater comfort, albeit shorter survival, among patients with advanced dementia and suspected pneumonia who were not treated with antimicrobials compared with those who were treated.

Another notable finding in this study was that the survival benefit associated with antimicrobial use (vs no treatment) was similar regardless of the route of administration, whereas the most aggressive treatment approaches (intravenous therapy or hospitalization) were associated with the greatest discomfort.
To date, no rigorously conducted study has reported the survival outcomes of patients in the final stages of other terminal diseases who did and did not receive antimicrobials for suspected infections.

APPROACHES TO DECISION MAKING,and NEXT STEPS -TO FOLLOW

G Mohan.