Home Forums General Medicine ANTIMICROBIALS at END OF LIFE CARE

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      Anonymous
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      APPROACH TO DECISION MAKING
      The decision of whether to prescribe antimicrobials can be challenging to address with terminally ill patients and their family members.
      Patients and families may incorrectly perceive antimicrobials as relatively benign and decisions about their use primarily under the purview of physicians.

      However, this issue should be approached using a framework of shared decision making similar to other end-of-life treatment choices.

      To the extent possible, decision making about antimicrobial use should be done as part of advance care planning rather than in the moment at the time of a crisis, with treatment preferences documented in advance directives (e.g., Physician/Provider Orders for Life Sustaining Treatment form).

      The initial move is to inform patients and families that infections are expected near the end of life, and are commonly a terminal event. Individuals should understand that even if the infection were cured, the underlying illness (eg, metastatic cancer, advanced dementia) would remain.

      Families and patients should also recognize what the evaluation of a suspected infection entails, and be advised about common scenarios that lead to unnecessary antimicrobial use (e.g., asymptomatic bacteriuria).
      The risks and burdens of evaluating and treating an infection should be presented, as well as the possible benefits, while acknowledging the lack of high-quality outcome data.
      In addition, the option of a purely palliative approach should be described (eg, oxygen, morphine, antipyretics).

      The ultimate goal of high-quality end-of-life care is to deliver treatment concordant with the patient’s goals and preferences. After providing basic information, the next step is to help patients and families decide which approach best aligns with the stated goals of care.

      If the preference is only for treatments that optimize comfort, it is reasonable to recommend that no evaluation be initiated for a suspected infection and palliative care provided.

      If the patient’s goal is to live as long as possible, and the potential benefits of antimicrobials are believed to outweigh its burdens, then it is reasonable to proceed with a clinical assessment for suspected infection.
      Provided there is adequate evidence to support a bacterial infection, antimicrobials by the least invasive route should be initiated and may offer the same survival benefit as parenteral therapy or hospitalization, but with less patient discomfort and health care expenditures.

      NEXT STEPS
      Improving infection management and optimizing the delivery of preference-based, safe, and cost-effective care to dying patients are currently 2 of the most pressing public health issues.

      Improving the care of terminally ill patients with suspected infections would require merging best practices and research initiatives from both infectious diseases and palliative care, and the collaboration of experts from both fields. Several opportunities exist.

      First, evidence-based and goal-directed counseling about infection management at the end of life must be a routine part of advance care planning and treatment discussions between clinicians and patients with advanced illness.

      Second, clinical algorithms aimed at improving antimicrobial stewardship from an infectious disease standpoint must also integrate treatment preferences when applied to patients near the end of life. Multifaceted clinical interventions that encompass patient and family counseling, clinician training, and appropriate antimicrobial prescribing should be designed and evaluated specifically for the palliative care setting.

      Third, to the extent that inadequate outcome data hinder decision making, researchers should consider whether there is adequate clinical equipoise and need to justify a carefully designed randomized trial comparing symptom control and survival among patients with advanced illness who receive antimicrobials vs high-quality palliative care for suspected infections.

      Antimicrobials are commonly prescribed at the end of life. Just as many other aspects of end-of-life care are being reconsidered, improving palliative care requires reassessment of the best use of antimicrobials in the final weeks of life.

      G Mohan.

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