Antibiotics in End-Of-Life Care

Antibiotics are used widely in all care settings in the months, weeks, days and even hours before death. The decision to start, or not start, antibiotic therapy in this context requires careful consideration. There is the potential for harm, both for the individual patient (through side-effects, including Clostridiodes difficile) and for the wider community (through promotion of antimicrobial resistance). Towards the end of life, though, there is added complexity: antibiotics may not change the clinical outcome but may mean that the patient’s care is overly medicalised and not aligned to what matters most to them.

National guidance has been produced by the Scottish Antimicrobial Prescibing Group (SAPG), including an information leaflet for patients, and this may help inform discussion about these issues.

Full guidance is available here:

Good practice recommendations for use of antibiotics towards the end of life

End of life antibiotics - information for patients

Summary of recommendations:

These recommendations apply to adults approaching the end of life. Here, ‘End of life’ is defined as the last few days or weeks of life, but it is acknowledged that the diagnosis or prediction of the actual 'end of life' is not always easy. Anticipatory care discussions with patient and families should ideally take place long before this point is reached.

1) Make shared decisions about future care

The evidence suggests this is the most important aspect of care for patients and their families/carers

• Decisions about antibiotic prescribing should be taken jointly between the clinician, the multi-disciplinary team, the patient and, where appropriate, their family/carer. This shared decision-making process not only involves informing the patient of the potential benefits and risks of antibiotics but also taking the time to understand the patient’s immediate priorities.
• Current and future antibiotic prescribing decisions should be discussed as part of anticipatory care planning conversations, documented in the clinical notes and included in the patient’s Key Information Summary. This discussion should include route of antibiotic therapy as intravenous treatment would usually necessitate hospital admission.

2) Agree clear goals and limits of therapy

These should be defined and agreed with the patient/family/carer after considering the following:

• The principal purpose of antibiotics at the end of life may be to relieve symptoms or may potentially be to cure infection.
• An infection should not necessarily be treated simply because it is treatable. Likewise, a positive microbiology result should not lead to an antibiotic prescription if there are no significant symptoms.
• Consider whether hospital admission if required for IV antibiotics is in keeping with the patient’s preferred place of care towards end of life.
• There are risks associated with giving antibiotics (including side effects, C. difficile and antimicrobial resistance).
• Infection may be reversible and clinicians may feel compelled to offer treatment. However, this should be balanced against potential antibiotic-related toxicity.
• If an antibiotic is prescribed, follow local guidance on drug choice, dose and duration and ensure a stop date is recorded.
• Overall benefit for each individual patient should be the goal of any treatment as per General Medical Council guidance on ‘Treatment and Care Towards End of Life’.
• Where patients lack capacity, guidance from the Adults with Incapacity Act 2000 should be followed, including, for example, involvement of a Power of Attorney /Guardian where appropriate. The preexisting wishes of the patient should be explored and considered in the context of the clinical situation. The benefits and risks of antibiotic therapy should be discussed with any proxy decision maker or family acting in the patient’s best interests.
• Other medicines including mucolytics, muscle relaxants, analgesics, anti-pyretics and antitussives should be considered as alternatives to antibiotics for relief of infection-related symptoms.
• Oxygen and non-pharmacological methods such as a hand held fan may be helpful for dyspnoea.
• Delirium is very common and often attributed wrongly to infection. It is important to consider other contributing factors (including that the person may be dying and terminally agitated).
• Seek advice from Palliative Care specialists if required.

3) Review all antibiotic prescribing decisions regularly

• If, in the context of an acute severe infection, it emerges that the patient is at the end of life, clinical decisions relating to antibiotic prescribing should be reviewed and discussed immediately.
• If it emerges that an antibiotic is not helping or is causing side effects, the discontinuation of treatment should be discussed with the patient and/or their carer/family.
• If the patient wishes to stop an antibiotic at any time, this decision should be respected and treatment should be discontinued.
• Antibiotic therapy should not routinely be escalated in the deteriorating patient at the end of life (this includes use of broad spectrum or intravenous antibiotics).