The use of antibiotics for bacterial infections is considered routine by many. Clinicians and lay people often view the withholding of antibiotics in the presence of bacterial infection as de facto neglect. On the other hand, some clinicians who refer patients to palliative care units or hospices still sometimes ask if their patients can receive antibiotics under the assumption that antibiotics are prohibited. This is not (or should not) be true. As for any other therapy, the real issue is the intent in giving antibiotics and whether antibiotics will be helpful in reaching certain goals.
Antibiotics may affect both the quality and quantity of life in complex ways.26 To the extent that antibiotics can help clear an infection that results in pneumonia even transiently, quality of life may be enhanced relative to that particular episode of pneumonia. Dyspnea, cough, fever, and delirium may all improve if the patient recovers. The use of antibiotics on the other hand, may adversely affect quality of life in that suppressing an existing infection without cure sometimes merely prolongs an acute, uncomfortable dying process from a day or two to several days. Even if a terminal patient briefly recovers, recurrent infection may result. In summing up the suffering inherent in (potentially) several such episodes before eventual death, the net quality of life may be worse with treatment than without. Antibiotics may have significant side effects, such as Clostridium difficile diarrhea caused by bacterial overgrowth as the normal gut flora is killed. Such side effects have a directly adverse effect on quality of life.
Antibiotics may or may not prolong life. It is almost a truism to point out that the closer a patient is to death, the less effect antibiotics will have on prolonging life. This has been best demonstrated for patients with Alzheimer's dementia.27 Volicer showed no significant difference in mortality of advanced Alzheimer patients treated for febrile episodes with or without antibiotics. For patients more mildly demented, there was a survival advantage to antibiotics. Studies are generally lacking for other terminal illnesses. However, the same principle seems to apply: the closer to death a patient is, the less difference antibiotics will make in prolonging life.
Whether life prolongation per se is seen as a benefit or burden will vary with the individual. Some patients will see any prolongation as a distinct burden. Even transient life prolongation, if possible, may be meaningful for others.
There are a number of situations in which antibiotics are clearly palliative. Pains of sinusitis, dental abscess, cellulitis, and parotitis, for example, are best treated with antibiotics, not morphine. These infections rarely cause death. The relative benefit or burden of life prolongation is not an issue.
At times, antibiotic therapy will appear to the clinician to be medically futile. That is, relative to certain goals (whether symptom relief or life prolongation), antibiotics will be judged to be ineffective. Once possible benefits (or lack thereof) and burdens have been raised, some will remain adamant in their demands that antibiotics be given. Patients and families may get stuck on a particular therapy such as antibiotics and be unable to get beyond what is often medically a rather trivial issue. In many such cases the relative harm of antibiotic administration to the dying patient is often minimal, as is the probability of medical response. In such cases the clinician may consider giving antibiotics (or similar therapies) in recognition that such requests arise out of psychological and cultural needs. The intent in such an approach is to remove the obstructing issue in the hope that the patient and family can move on to the more important work of coping with the impending loss of the patient. Physicians may be fearful that one request will lead only to increasingly unreasonable requests. Although this can happen, in my experience it is more likely that demonstrating flexibility will be appreciated and will enhance the relationship. Beneath most requests for antibiotics is a simple desire for provision of the best possible care and a hope that we not abandon the patient. If we can convince patients and families of this, we will establish an enduring relationship beneficial to all.
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Palliative Care Perspectives
James L. Hallenbeck, M.D.
Copyright © 2003 by Oxford University Press, Inc.
The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.