Wednesday, January 15, 2014
Antibiotics in hospice
Case 1: You have a 94 year old woman with multiple medical problems in hospice who develops a fever (subjectively hot to the touch), shortness of breath, and a cough producing yellow sputum. Her daughter asks if she can be treated with antibiotics "to make her feel better." The patient is not well enough to make decisions, but in earlier conversations had stated a goal of remaining comfortable at home, while also hoping to live until her first great grandchild is born. Should you treat with antibiotics?
Case 2: You have an 84 year old man in the hospital being treated for a fungal infection of the heart. The condition is non-operable and he decides to focus on comfort. The plan is to discharge to hospice. The infectious disease team recommends a 12 week course of IV antifungals, or at the every least oral anti-fungals. The patient, who has already had one stroke from a fungal clot in his heart that shot up to his brain, is willing to take the medication. Should you follow these recommendations?
Case 3: You have a 98 year old woman with advanced dementia on hospice in the nursing home. She is unable to speak and is fed by hand. She develops a fever, is urinating more frequently, grimacing and moaning. Should you send a UA? Should you treat with antibiotics?
Though loosly based on real world expereinces, these cases are all made up.
The role of antibiotics in hospice is far from clear-cut. A recent paper by a group from the Oregan Health Sciences University led by Jennifer Albrecht, PhD, used a national dataset of hospice agencies to investigate use of antibiotics in hospice. They found that 27% of patients received at least one antibiotic in the last week of life. These numbers, they note, are lower than previous estimates. That is still a lot of antibiotics!
The data from other studies seem to suggest that antibiotics are beneficial in terms of symptom relief only for urinary tract infections, as in Case 3. The data are retrospective, and by no means definitive (see citations in Albrecht's paper).
In my experience there are a lot of gray areas where the decision of whether or not to prescribe an antibiotic is far from clear. How much is the antibiotic directed at symptom relief? At prolonging life? As the Jennifer Albrecht notes, the goals of patients in hospice are also often mixed, and many patients have some mixture of goals oriented toward quality of life and extending life, as in Case 1. They also note that while preferences for CPR are commonly documented, preferences for antibiotic use are not.
Patient, caregiver, and provider beliefs about the effectiveness of antibiotics vary widely. If we struggle to constrain antibiotic prescribing for upper respiratory tract infections with healthy ambulatory patients in primary care, think of how much more charged these conversations can be at the end of life.
We need more clarity in this area. It's a rich area, involving symptom relief and communication, topics at the heart of hospice and palliative care. Hopefully there are some researchers out there willing to take this on!