Treatment with antibiotics in end-of-life care does not allow for uniform improvement in patient symptoms. The decision of whether to treat an infection at the end of life is complicated, both medically and emotionally.

The use of antibiotics at the end of life is highly variable. Different studies report that:
• 87% of hospitalized patients with advanced cancer received antibiotics in the terminal hospitalization; of those, fewer than 50% had a documented infection.
• 27% of patients in home hospice care received antibiotics in the last week of life; of those, 15% had a documented infection. The results were irrespective of region, diagnosis, or socioeconomic status.
• Even for cancer patients who were in "comfort care," antibiotics were continued in up to one-third of patients. Eventual discontinuation was at approximately 1 day prior to death.

Treatment with antibiotics for a suspected infection can be part of a plan to provide comfort care, but is that benefit is still present in patients one day prior to death?

The goal of reducing symptom burden may be the most compelling argument leading to antibiotic treatment. Data supporting relief of symptoms are variable, and relief is inconsistently measured.
There is wide variability in antibiotic use in hospice and palliative care settings and inconsistencies in the definition of improvement, ranging from resolution of fever, to improvement in control of other symptoms. In studies that report benefit in treatment, the improvement varied by site of primary infection — generally patients at the end of life with symptomatic urinary tract infection obtain symptomatic improvement when treated with antibiotics. Few data show that using antibiotics to treat infections in the respiratory tract, oral cavity, or skin leads to symptomatic improvement.

The desire to prolong survival is a factor that may lead to use of antibiotics at the end of life. No study has reported the survival outcomes of patients with a suspected infection at the end of life who were treated versus those where treatment was not provided. Health personnel often perceive that antibiotics are less troublesome than other “aggressive interventions,” such as mechanical ventilation, hemodialysis, transfusions, or artificial feeds. And antibiotics are more likely to fall under "usual care," thus receiving less scrutiny.

The burdens of antibiotic use often go unappreciated. Antimicrobial adverse effects including diarrhea, allergic reactions, nausea, and anorexia are important. Antimicrobial use may necessitate the use of a peripheral intravenous line, leading to increased logistic efforts. There are also significant drug interactions with antimicrobials and medications used at the end of life: the most problematic for patients is antimicrobials and methadone, as it inhibits the CYP3A4 enzyme and thus makes it dangerous when combined with fluoroquinolones or macrolides.
Moreover, there is potential for the development of secondary infection from antimicrobial use, such as Clostridium difficile.

The continuation of parenteral antibiotics can often result in a delay to the transition to a more comfort-based environment, prolonging a patient's hospital course and resulting in additional invasive and costly testing.

Ethical considerations.
Respect for autonomy gives the patient and family the right to request or reject medical treatment based on their values and beliefs. The absence of supportive updated data concerning the use or non-use of antibiotics at the end of life makes it difficult to achieve the balance of benefit versus harm, and action versus inaction.

Providing health personnel with data on the benefits of comfort care at the end of life can assist in directing the decision to forgo antimicrobial treatment. Here are some examples.
• The relief of cough or dyspnea with opiates in a patient with pneumonia is a viable alternative to antimicrobial therapy.
• Treat fever with antipyretics or steroids, and only offer antibiotics as a consideration when clinicians are targeting a specific infection.
• Antibiotics are not helpful, and even harmful, when death is imminent and patients cannot take oral medications or there is multisystem failure.

See reference for more information.

Adapted from Leigh Vaughan L et al. News@Perspective. Ethical and clinical considerations in treating infections at the end of life. Internet. Available at https://www.medscape.com/viewarticle/910625_3. Accessed on May 15, 2019. To view the entire article and all other content on the Medscape News and Perspective site, a free, one-time registration is required.