In the Journals

Early palliative care consultation reduces antimicrobial consumption at end of life

Jason Burnham
Jason P. Burnham

Early palliative care consultation may reduce antimicrobial consumption in patients at the end of life, according to recently published study findings.

“Physicians often choose to continue antibiotics to improve quality of life or reduce symptom burden. However, whether these outcomes are achieved is unclear, with some studies showing no difference,” Jason P. Burnham, MD, instructor in medicine in the division of infectious diseases at Washington University School of Medicine, told Infectious Disease News.

“There are ample data to suggest that antibiotics are overprescribed for urinary and respiratory infections — in general, not just at the end of life — when there are alternative explanations for patients’ symptoms — viral infections, non-infectious causes. There may be some reasons to give antibiotics at the end of life, but currently we probably prescribe them too often and with unclear benefits.”

For their single-center, cluster randomized crossover trial, Burnham and colleagues collected data from patients at Barnes-Jewish Hospital in St. Louis from August 2017 to May 2018. The trial included a 6-week washout period in the middle of the study that was followed by a cross over to the intervention or continuing with usual care in the two medical ICUs, Burnham and colleagues explained.

Participants were adult patients with a high risk for morbidity and mortality based on predetermined palliative care screening. In the intervention arm, patients were given palliative care within 48 hours of ICU admission. The control group included patients who received palliative care at their physician’s discretion.

Burnham and colleagues included data from 132 patients who survived to hospital discharge and were not on suppressive antimicrobials or active treatment for a prior infection when they were admitted, including 27.3% (n = 36) who changed their code status to “do not resuscitate/do not intubate.” Among these patients, 16.7% (n = 6) were discharged with antibiotics — a “significantly lower” proportion than was seen in the 96 patients who did not change their code status, 37.5% (n = 36) of whom received antibiotics at discharge, Burnham and colleagues said. None of the 23 patients discharged to hospice received antibiotics.

Most patients — 87.9% — died or had data available for 30 days following their discharge. Burnham and colleagues said they found no difference in the proportion of patients discharged with antimicrobials among those who died within 30 days and those who did not.

“What patients want at the end of life is something we as clinicians should strive to clarify. A key decision to make is when and when not to use antibiotics at the end of life. This decision should be influenced by the knowledge that antibiotics may provide no symptomatic or quality-of-life benefit while potentially incurring side effects that could paradoxically increase symptoms or worsen quality of life,” Burnham said. “In addition, palliative care consultation should be performed for all patients at the end-of-life — this is best practice for patients. A byproduct of this is likely to be a reduction in antimicrobial use.” – by Erin Michael

Disclosures: The authors report no relevant financial disclosures.

Jason Burnham
Jason P. Burnham

Early palliative care consultation may reduce antimicrobial consumption in patients at the end of life, according to recently published study findings.

“Physicians often choose to continue antibiotics to improve quality of life or reduce symptom burden. However, whether these outcomes are achieved is unclear, with some studies showing no difference,” Jason P. Burnham, MD, instructor in medicine in the division of infectious diseases at Washington University School of Medicine, told Infectious Disease News.

“There are ample data to suggest that antibiotics are overprescribed for urinary and respiratory infections — in general, not just at the end of life — when there are alternative explanations for patients’ symptoms — viral infections, non-infectious causes. There may be some reasons to give antibiotics at the end of life, but currently we probably prescribe them too often and with unclear benefits.”

For their single-center, cluster randomized crossover trial, Burnham and colleagues collected data from patients at Barnes-Jewish Hospital in St. Louis from August 2017 to May 2018. The trial included a 6-week washout period in the middle of the study that was followed by a cross over to the intervention or continuing with usual care in the two medical ICUs, Burnham and colleagues explained.

Participants were adult patients with a high risk for morbidity and mortality based on predetermined palliative care screening. In the intervention arm, patients were given palliative care within 48 hours of ICU admission. The control group included patients who received palliative care at their physician’s discretion.

Burnham and colleagues included data from 132 patients who survived to hospital discharge and were not on suppressive antimicrobials or active treatment for a prior infection when they were admitted, including 27.3% (n = 36) who changed their code status to “do not resuscitate/do not intubate.” Among these patients, 16.7% (n = 6) were discharged with antibiotics — a “significantly lower” proportion than was seen in the 96 patients who did not change their code status, 37.5% (n = 36) of whom received antibiotics at discharge, Burnham and colleagues said. None of the 23 patients discharged to hospice received antibiotics.

Most patients — 87.9% — died or had data available for 30 days following their discharge. Burnham and colleagues said they found no difference in the proportion of patients discharged with antimicrobials among those who died within 30 days and those who did not.

“What patients want at the end of life is something we as clinicians should strive to clarify. A key decision to make is when and when not to use antibiotics at the end of life. This decision should be influenced by the knowledge that antibiotics may provide no symptomatic or quality-of-life benefit while potentially incurring side effects that could paradoxically increase symptoms or worsen quality of life,” Burnham said. “In addition, palliative care consultation should be performed for all patients at the end-of-life — this is best practice for patients. A byproduct of this is likely to be a reduction in antimicrobial use.” – by Erin Michael

Disclosures: The authors report no relevant financial disclosures.