In hospice care, our primary goal is to maximize patient comfort while adhering to a patient’s and family’s goals of care. We work to accomplish these goals by employing an interdisciplinary team approach to address all aspects of the patient’s plan of care. Of course, medications are a mainstay of our treatment plan to ensure patient comfort and symptom palliation. A class of medications that can elicit questions on benefit and purpose is certainly antibiotics.
Proper Use of Antibiotics
I would imagine that most of us have been prescribed an antibiotic for some ailment throughout our lives. Over the last ten years, inappropriate antibiotic use has been a focus area for the CDC (Centers for Disease Control) and WHO (World Health Organization). In 2013, both organizations declared antibiotic resistance a national and global threat. In their joint statement, they stated that “Antibiotic use is the most important modifiable driver of antibiotic resistance.” Vast campaigns were employed to educate both prescribers and patients about the risks of inappropriate antibiotic usage. Per Dr. Amesh Adalja, MD, the Infectious Diseases Society of America Spokesperson, “Antibiotics are misused so often because of the belief that these are benign drugs, and that patient satisfaction depends upon being prescribed an antibiotic.”
In a hospice population, our patients are at a higher risk for infection and are at higher risk for more severe infections due to the nature of their underlying illnesses and morbidity. However, our patients are also at higher risk of medication toxicities. Thus, we must balance these two issues based on patient and/or family preference. Hospice-based studies report overall antimicrobial use ranging from 8-37%, and 27% of hospice patients receive at least one antibiotic in the last week of life. At Hospice of Southern Illinois, we strive to focus on “Person-Centered Care”. Hence, we confirm there is evidence to support the treatment, the benefit of treatment outweighs the risks, and the patient and/or family should be involved in the decision-making process.
Are Antibiotics the Right Fit?
When determining if an antibiotic is appropriate in end-of-life care, consider multiple factors. In addition to comfort and symptom goals, we look at estimated prognosis, swallowing function of the patient, and the risk of infection progression and/or recurrence. Regarding antibiotics in hospice care, most of the evidence for symptom benefit exists for urinary tract infections, with a symptom response rate up to 92%. Respiratory illnesses are often viral, and symptom responses can vary from 0-53%. Bloodstream infections, commonly known as sepsis, have the least symptomatic benefit from antibiotics. Also, the administration of antibiotics rarely improves symptoms in the last week of life.
As mentioned above, antibiotics can have side effects, varying from mild to severe and acute to irreversible. These can include nausea, vomiting, loose stools, rash, agitation, secondary yeast infections, electrolyte imbalances, cardiac arrhythmias, seizures, renal toxicity, and anaphylaxis. Equally important, certain antibiotics should also have reduced doses or increased dosing intervals due to declining kidney or liver function. However, this declining function may not always be apparent in a hospice patient as routine laboratory studies are often aborted for patient comfort. There are also multiple possible antibiotic-drug interactions to consider.
The Importance of Collaborative Planning
It is important to involve the patient and the caregiver early in the care-planning process to discuss and document antibiotic preferences. Planned discussions at the time of hospice admissions or care plan meetings should be utilized, as well as any changes in patient condition. When an infection is suspected based on patient symptomatology or diagnosed based on laboratory or imaging studies, health care providers and caregivers should first focus on whether the infection symptoms are impacting the quality of life. If so, we should then default to our patient’s preferences based on prior discussions.
Non-antibiotic symptom management approaches should always be part of the infection plan of care, with or without antibiotics. Furthermore, these techniques support antibiotic stewardship, compliance with organizational recommendations, and patient advocacy. Please reach out to Hospice of Southern Illinois as your preferred end-of-life care provider. Above all, we take pride in our care of our patients and families and our community at large.
References:
- Rosenberg JH, Albrecht JS, Fromme EK, et al. Antimicrobial use for symptom management in patients receiving hospice and palliative care: a systematic review. J Palliat Med. 2013: 16(12):1568-1574.
- Albrecht JS, McGregor JC, Fromme EK, et al. Nationwide analysis of antibiotic use in hospice care in the final week of life. J Pain Symptom Manage. 2013;46(4):483-490.
- Vitetta L, Kenner D, Sail A. Bacterial infections in terminally ill hospice patients. J Pain Symptom Manage. 2000;20(5):326-334.
- White P, Kuhlenschmidt H, Vancura B, Navari R. Antimicrobial use in patients with advanced cancer receiving hospice care. J Pain Symptom Manage. 2003;25(5):438-443.
- Reinbolt R, Shenk A, White P, Navari R. Symptomatic treatment of infections in patients with advanced cancer receiving hospice care. J Pain Symptom Manage. 2005;30(2):175-182.
- Baghban A, Juthani-Mehta M. Antimicrobial use at the end of life. Infect Dis Clin N Am. 2017;31:639-47.
- Givens JL, Jones RN, Shaffer ML, Kiely DK, Mitchell SL. Survival and comfort after treatment of pneumonia in advanced dementia patients. Arc Intern Med. 2010:170(13):1102-1107.
- Nakagawa S, Toya Y, Okamoto Y, et al. Can anti-infectives drugs improve the infection-related symptoms of patients with cancer during the terminal stages of their lives? J Palliat Med. 2010:13(5):535-540.
- Sinert MS, Schmidt MM, Lovell AG, et al. Guidance for safe and appropriate use of antibiotics in hospice using a collaborative decision support tool. J Hosp Pall Nurs. 2020:22(4)1-7.
