Skip to main content

Drugs and Bugs at the End of Life


by: Eric Widera @ewidera

The majority of hospitalized patients with advanced cancer are given antibiotics in the last week of life. Nearly half of those individuals living in nursing homes with advanced dementia are given antibiotics in the last two weeks of life.  And yes, even in hospice, one out of four individuals  are given antibiotics within the last weeks of life.  If one would just go by numbers, it would seem that antibiotics are a mainstay of palliative care.

So that begs the question, are these medications really benefiting the patient? In this weeks JAMA, Manisha Juthani-Mehta, Preeti Malani, and Susan Mitchell wrote about these issues in a piece titled Antimicrobials at the End of Life: An Opportunity to Improve Palliative Care and Infection Management."

It’s a short piece that makes a good quick read, and best of all, it is free! The risks of antibiotics are discussed including drug reactions, drug-drug interactions, and C. difficile infection, as well as the burden diagnostic testing (blood draws) and treatments (IV lines). The potential benefits are discussed, as well as potential next steps including the need to merge “best practices and research initiatives from both infectious diseases and palliative care,” which sounds like at the very least a wonderful topic for a future AAHPM or AGS symposium (hint hint Dr. Malani).

The one thing I’m still hemming and hawing over is the recommendation that “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.” Antibiotics are just one of the many potential medical interventions that are often given near the end of life. Talking about all of these options may be overwhelming for patients and family members, and distract from the more important aspect of advance care planning which is figuring out goals and values.

With that said, I think this article serves as an important reminder for me.  Next time I utter the phrase "lets just finish off the course of antibiotics" when admitting a hospice patient, I will stop and think "does this patient actually need to be on it in the first place?"


Comments

Marian Grant, RN, CRNP said…
Perhaps this will become another measure of suboptimal care, like chemotherapy in the last weeks of life.
Anonymous said…
I think that Hindsight here might be a problem. I can't tell you how many times abx have helped my mom, be it a UTI, or something from her COPD. It also helps the clarity of her mind. I suspect, when she dies, she may be on abx, but that fact won't acknowledge the many times that they extended her quality of life.

IF we know these are the last weeks of life, we may well take different actions, but I can't tell you how many times we thought these were the last weeks for Mom, over the last many years.

Regardless though, I think it's always good to evaluate whether the drugs are really needed. It's also important for clinicians to be aware that often elderly patients don't mount a typical response to infection, so they miss it. I would just hate for there to be a movement that withholds medication that might be appropriate and helpful.

LisaT

Popular posts from this blog

Geroscience and it's Impact on the Human Healthspan: A podcast with John Newman

Ok, I'll admit it. When I hear the phrase "the biology of aging" I'm mentally preparing myself to only understand about 5% of what the presenter is going to talk about (that's on a good day).  While I have words like telomeres, sirtuins, or senolytics memorized for the boards, I've never been able to see how this applies to my clinical practice as it always feels so theoretical.  Well, today that changed for me thanks to our podcast interview with John Newman, a "geroscientist" and geriatrician here at UCSF and at the Buck Institute for Research on Aging.

In this podcast, John breaks down what geroscience is and how it impacts how we think about many age-related conditions and diseases. For example, rather than thinking about multimorbidity as the random collection of multiple different clinical problems, we can see it as an expression of the fundamental mechanisms of aging. This means, that rather than treating individuals diseases, targeting …

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Length of Stay in Nursing Homes at the End of Life

One out of every four of us will die while residing in a nursing home. For most of us, that stay in a nursing home will be brief, although this may depend upon social and demographic variables like our gender, net worth, and marital status. These are the conclusions of an important new study published in JAGS by Kelly and colleagues (many of whom are geripal contributors, including Alex Smith and Ken Covinsky).

The study authors used data from the Health and Retirement Study (HRS) to describe the lengths of stay of older adults who resided in nursing homes at the end of life. What they found was that out of the 8,433 study participants who died between 1992 and 2006, 27.3% of resided in a nursing home prior to their death. Most of these patients (70%) actually died in the nursing home without being transferred to another setting like a hospital.

 The length of stay data were striking:

the median length of stay in a nursing home before death was 5 months the average length of stay was l…