Antibiotics in end-of-life care

Background (age, sex, occupation, baseline function)

• 79-year-old male
• Nursing home resident currently admitted to hospital

History of presentation/reason for review

• One week ago: worsening cough, shortness of breath and acute confusion
• Deterioration over last three days and now on day four of five-day course of doxycycline for presumed pneumonia
• Last 24 hours: difficulty swallowing, drowsy and too unwell to discuss treatment approach. Discussion with son and admitted to hospital for treatment of suspected pneumonia and dehydration
• Oral candidiasis

Current medical history and relevant co-morbidities

• Non-small cell lung cancer with bone, liver and adrenal metastases diagnosed three months ago. For symptomatic management as not fit for chemotherapy
• Parkinson’s disease (PD) – 10 years ago
• Chronic kidney disease – 14 years ago
• Ischaemic heart disease (IHD) and hypertension – 18 years ago

Current medication and drug allergies (include over the counter (OTC) preparation, traditional medicines and herbal remedies)

Allergies or adverse drugs reactions (ADRs): nil

Currently prescribed: 

• Amlodipine 5mg tablets: one tablet daily
• Aspirin 75mg dispersible tablets: one tablet daily
• Co-beneldopa 100/25mg capsules: one capsule every six hours
• Macrogol 3350 sachets: one sachet twice daily
• Paracetamol 500mg caplets: two caplets every six hours
• Quinine sulfate 200mg tablets: one tablet at night
• Senna 7.5mg tablets: two tablets at night
• Simvastatin 40mg tablets: one tablet at night
• Thiamine 100mg tablets: one tablet three times daily

Over the counter medicines: nil

Lifestyle and current function

• Clinical frailty score (Rockwood) seven (severely frail)
• Previous alcohol excess, has been abstinent for five years

“What matters to me” (ideas, concerns and expectations of treatment)

• Community DNACPR order
• Advance Care Plan in place, listing care home as preferred place of death with ‘consider hospital admission for reversible conditions’

Observations, examinations and results 

Note: local laboratory reference ranges may vary

• New confusion – abbreviated mental test (AMT) 0/4
• Weight 52kg, Height 167cm, BMI 18.6kg/m²
• BP 100/55mmHg, pulse 110bpm
• Respiratory rate 26 per minute; coarse bilateral crepitations on auscultation
• Temperature 35.5°C
• Urea and Electrolytes:
  • Urea 22.0mmol/L (2.5-7.8mmol/L)
  • eGFR 33 ml/min/1.73m²
  • Creatinine 180micromol/L, (60-120micromol/L), calculated creatinine clearance 21ml/min
  • Albumin 15g/dL (3-50g/dL)
• CRP 75mg/L (0-10mg/L)
• Adjusted calcium 3.21mmol/L (2.20 -2.60mmol/L)

Most recent relevant consultations

Following admission to hospital:

• Intravenous (IV) antibiotics and fluids commenced for treatment of community acquired pneumonia and IV pamidronate for hypercalcaemia of malignancy
• Visibly worsening despite 24 hours of IV treatment
• Agitated and pulling out vascular devices
• Incontinent of loose stools (sample sent for Clostridioides difficile (C. diff))

Person specific issues to address

Anticipatory care plan in place includes desire for

• comfort at the end of life
• end-of-life care to be in nursing home

 

Person specific issues to address

• Parkinson’s medicines are essential. Specialist input on replacement for oral formulations. Options include:
  • dispersible medication if easier to swallow
  • nasogastric to deliver medication (unlikely to be useful here due to agitation)
  • switch to rotigotine patches to control distressing PD symptoms and potentially improve swallowing. See notes below
• Antibiotics can be essential but need to be reviewed regularly

 

Person specific issues to address

• Majority of medicines should be stopped: amlodipine, aspirin, quinine, simvastatin, thiamine are of no benefit in short-term and should be stopped rather than converted to non-oral forms.
• Macrogol and senna should be stopped due to diarrhoea

 

Person specific issues to address

• Failure to improve with IV antibiotics and fluids in the context of very advanced malignancy, is not unexpected
• Advanced care directive specified the wish to die at nursing home, and to be comfortable at the end of life
• Management of agitation and pain control need to be considered

 

Person specific issues to address

• IV access and blood monitoring are painful and potentially distressing which needs balancing against benefits and risks such as Staphylococcus aureus bacteraemia (SAB)
• Oral candidiasis can be caused /worsened by antibiotics
• Diarrhoea and C. diff infection are risks secondary to antibiotics and exacerbated by laxatives. Stool sample sent to assess for C. diff infection

 

Person specific issues to address

• Whilst there are associated financial and environmental costs with IV antibiotics and use of vascular devices, there is also “opportunity cost”: IV treatment preparation, administration and monitoring diverts nursing time away from delivering direct care to the individual at end-of-life
• Care home advised to dispose of medicines no longer required through community pharmacy

 

Agreed plan

• The individual’s wishes made when they were capable remain the core factor guiding management decisions
• Adult now lacks capacity and incapacity certificate required
• Failure to improve on antibiotic treatment should prompt consideration of discontinuation
• The ongoing benefit of fluids and treatment to lower calcium need to be considered, and whether to stop
• Consider whether replacement needed for co-beneldopa and involve local Parkinson’s service
• Stop non-essential medication
• Pain is a cause of agitation and appropriate pain relief should be considered to address this.
• Treat oral candidiasis with topical or systemic therapy
• Consider involving local palliative care service