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An audit on antibiotic use at the end of life in inpatient hospice patients – Are we contributing to over-medicalization of dying?

Abstract Background The use of antibiotics is common in patients under hospice care, although there are no definite guidelines on its use at the end of life. The excessive use of antibiotics, especially in the terminal phase when its benefit is questionable, may encourage development of antibiotic resistance and add to the cost and burden of care. Objective We conducted an audit on the use of antibiotics during the inpatient hospice stay, studying the indications, effectiveness, and appropriateness of its use. Methods We conducted a retrospective case note review of the use of antibiotics in patients who died in an inpatient hospice over a 3-month period. We extracted data on the use of antibiotics, type of infections, symptomatic response to antibiotics, and timing of antibiotic use in relation to death. Results Twenty-two (17.3%) out of 127 patients were treated with antibiotics during their inpatient hospice stay. Patients with symptoms of urinary tract infection such as fever, dysuria, frequency, and urgency had 75% response rate with the use of antibiotics. Patients with symptoms of respiratory tract infection such as fever, cough, sputum production, and dyspnea had 66.6% response rate with the use of antibiotics. The prevalence of use of antibiotics in the last 1 week of life was 3.1%. The prevalence of use of antibiotics in the last 24 hours of life was 2.3%. Patients who did not have symptomatic response to antibiotics were on antibiotics for mean of 3.7 days. Conclusion The audit revealed that there were clear indications on the use of antibiotics in all patients. Majority of patients showed symptomatic response to the use of antibiotics. Use of the antibiotics was rational and not excessive. Recommendations for use of antibiotics at the end of life include: (1) clear documentation on indications and goals of care consistent with patient wishes, (2) antibiotic use to be guided empirically, and (3) review and withdrawal of antibiotics when it no longer meets the goals of care.