Antibiotic use at end-of-life

The decision to start or not start antibiotic therapy, requires careful consideration as there are potential side effects, which may add to the symptom burden at end-of-life. Care is needed to ensure management aligns with what matters most to the individual to prevent care being overly medicalised. Clear goals and limits of therapy should be discussed.

Other medicines including mucolytics, muscle relaxants, analgesics, antipyretics and antitussives, can be used as alternatives for relief of infection-related symptoms.

Antibiotics are one of the most prescribed medications and can be an essential treatment option for the prevention and treatment of infections. Approximately one in three patients in hospital receive an antibiotic but this is a small proportion of total antibiotics prescribed, as 83% are prescribed in a primary care setting.²⁷⁰ Long-term antibiotics should be reviewed as part of a 7-Steps polypharmacy review to ensure continued indication for their use.

Antimicrobial resistance (AMR) arises when micro-organisms, such as bacteria, develop the ability to withstand antimicrobial treatments making infections harder to treat which can result in severe disease and potentially death. To slow resistance, avoid the unnecessary use of antibiotics.

Anticipatory care plans should be created and clearly documented before the person becomes acutely unwell and can be used to make informed decisions about what matters to them. Shared decision-making about prescribing antibiotics towards the end of life should be taken jointly between the prescriber, wider multidisciplinary team and individual (and/or family/carers/welfare power of attorney as appropriate). This ensures the individual is aware of the potential benefits and risks, including when an antibiotic would or would not be prescribed.

Antibiotics may be indicated to relieve symptoms or potentially cure an infection at the end-of-life, for example:

• a three-day course of appropriate antibiotics such as trimethoprim or nitrofurantoin will reduce the duration of symptoms of a lower urinary tract infection (UTI) in women
• treatment of painful conditions, such as cellulitis, candidiasis

The benefit of treatment of pneumonia at end-of-life is much less clear. Risks and benefits should be considered including when treatment would require hospitalisation, but individual preference is for end-of-life care at home.

There are risks associated with giving antibiotics including side effects, e.g. oral or vaginal candidiasis, C. diff infection and AMR.

Giving antibiotics intravenously is more invasive and increases the risk of secondary local infection.

Antibiotic therapy should not routinely be escalated in the deteriorating individual at the end-of-life. If the antibiotic is not helping, is causing side effects or the individual wishes, it can be stopped.

Specific areas/situations where medication may need to be introduced or increased

Antibiotics may be introduced to relieve symptoms or potentially cure an infection.

Overall benefit for each individual should be the goal of any treatment as per General Medical Council’s ethical guidance summary Treatment and care towards the end of life.²⁷⁴

Palliation of symptoms at end-of-life is of utmost importance. See the Scottish Palliative Care Guidelines - End of Life Care.¹⁵⁸ SAPG provide further information and guidance on antibiotic use at end of life.

Does the person understand the outcomes of the review, including risk and benefits?

• Is the individual able to take the antibiotic as prescribed or are other formulations/support required?

Is drug therapy tailored to the individual?

• Anticipatory care discussions with individual and family/carers should ideally take place long before the very final stages of decline.
• Future antibiotic prescribing decisions (including route of therapy) should be discussed, documented in the clinical notes and included in the individual’s Key Information Summary.

Agree the plan

• Individuals can continue to discuss ongoing treatment and plans should be reassessed if there are improvements or deterioration in the individual’s condition.

• self-management/support tools
• decision aids

Future Care Planning (REDMAP) resource on TURAS

Information for patients on future care planning is available on NHS inform