Can patients receiving comfort measures still receive intravenous (IV) antibiotics?

From the Guidelines

Patients receiving comfort measures can still receive intravenous (IV) antibiotics, but this decision should be made on a case-by-case basis, considering the potential benefits and burdens of antibiotic therapy in the context of the patient's goals of care. When deciding whether to administer IV antibiotics to patients on comfort measures, it is essential to weigh the potential benefits of symptom alleviation against the potential risks and burdens of treatment, as highlighted in the guidelines for implementing an antibiotic stewardship program 1.

Key Considerations

• The impact of antibiotic therapy on symptom alleviation should be considered in the context of specific infections, such as urinary tract infections or pneumonia 1.
• The route of administration should be considered, with oral antibiotics preferred whenever possible to minimize the burden of IV access and monitoring 1.
• The potential for adverse effects, such as Clostridioides difficile infection (CDI), and public health risks should be taken into account 1.
• Patients and their surrogates should be engaged in the decision to use antibiotic agents at end of life, ensuring that the treatment aligns with the patient's goals of care 1.

Treatment Approach

• IV antibiotics may be appropriate if they would alleviate distressing symptoms like pain, fever, or respiratory distress caused by infection, such as ceftriaxone 1-2g IV daily for a urinary tract infection or azithromycin 500mg IV daily for pneumonia 1.
• The decision to start or continue antibiotic therapy should be made in collaboration with the patient's healthcare team, considering the patient's or family's preferences and the overall comfort-focused plan 1.
• Antibiotic therapy should be viewed as aggressive care in the end-of-life setting and should be discontinued if it is not improving symptoms or if it becomes burdensome to the patient 1.

From the Research

Administration of IV Antibiotics to Patients Receiving Comfort Measures

• Patients receiving comfort measures can still receive intravenous (IV) antibiotics, as evidenced by studies that show antimicrobial use is relatively high in hospitalized patients near the end of life, even when the goal is comfort 2.
• A study found that 77% of patients who transitioned to a comfort care protocol received antimicrobials during their admission, and 15.6% of patients alive at ≥24 hours after comfort care orders were still on antimicrobials 2.
• Another study reported that 26% of patients who were on antimicrobials in the 48 hours prior to comfort measures only (CMO) remained on antimicrobials after the transition to CMO, with patient/family preference and symptom palliation being the most common factors cited for continuing antimicrobials 3.
• However, there may be inconsistencies in patient wishes, with some patients desiring comfort measures only while also wanting to receive IV fluids and/or antibiotics, highlighting the need for clear communication and decision-making 4.

Considerations for IV Antibiotic Use in Comfort Care

• The decision to use IV antibiotics in patients receiving comfort measures should be based on individual patient needs and goals, taking into account factors such as symptom palliation and patient/family preference 3, 5.
• Clinicians should be aware of the potential benefits and burdens of antimicrobial treatment in this population, including the risk of developing multiresistant nosocomial Gram-negative bacilli 6.
• Nurses play a crucial role in helping patients and families navigate the decision to use or forgo antibiotics at the end of life, and should be involved in discussions about the potential benefits and burdens of treatment 5.