{"id":5815,"date":"2015-02-15T17:18:02","date_gmt":"2015-02-15T22:18:02","guid":{"rendered":"http:\/\/blogs.nejm.org\/hiv-id-observations\/?p=5815"},"modified":"2024-05-01T13:46:46","modified_gmt":"2024-05-01T17:46:46","slug":"should-antibiotics-be-part-of-end-of-life-care","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/should-antibiotics-be-part-of-end-of-life-care\/2015\/02\/15\/","title":{"rendered":"Should Antibiotics be Part of End-of-Life Care?"},"content":{"rendered":"<p>There&#8217;s been some truly outstanding work done recently\u00a0on\u00a0end-of-life care, and how we deal with it &#8212; or more accurately, how we typically\u00a0<em>don&#8217;t<\/em> deal with it until the very last moment, at which time often many\u00a0unfortunate decisions and\u00a0events occur. Here are three I can strongly recommend:<\/p>\n<ul>\n<li>Roz Chast&#8217;s <em><strong><a href=\"http:\/\/www.amazon.com\/Cant-Talk-about-Something-Pleasant\/dp\/1608198065\" target=\"_blank\" rel=\"noopener noreferrer\">Can&#8217;t We Talk About Something More Pleasant?<\/a><\/strong>\u00a0<\/em>is probably the most widely read book among my circle of friends right now, as many of us\u00a0have parents of a certain age.<em>\u00a0<\/em>Chast is a cartoonist best known for her distinctive squiggly cartoons in the <em>The New Yorker &#8212; <\/em><strong><a href=\"https:\/\/condenaststore.com\/featured\/narcissist-cards-roz-chast.html?product=art-print\" target=\"_blank\" rel=\"noopener noreferrer\">here&#8217;s one of my favorites<\/a><\/strong> &#8212;\u00a0and\u00a0is already familiar\u00a0to many ID doctors because of her <strong><a href=\"http:\/\/www.nytimes.com\/imagepages\/2006\/12\/04\/books\/05chast1.html\" target=\"_blank\" rel=\"noopener noreferrer\">morbid fascination with dreadful diseases<\/a><\/strong>, some\u00a0of them infections. But this extended memoir about her aging parents is a remarkably ambitious book, by turns funny (of course), moving, and ultimately heartbreaking, especially when touching on the fraught relationship she had with her mother.<\/li>\n<li>If drawings\u00a0aren&#8217;t your thing, then give Atul Gawande&#8217;s <a href=\"http:\/\/www.amazon.com\/Being-Mortal-Illness-Medicine-Matters-ebook\/dp\/B00JCW0BCY\/ref=sr_1_1?s=books&amp;ie=UTF8&amp;qid=1424010732&amp;sr=1-1&amp;keywords=being+mortal\" target=\"_blank\" rel=\"noopener noreferrer\"><strong><em>Being Mortal<\/em><\/strong><\/a> a shot. In his usual clear prose &#8212; which miraculously reads\u00a0neither overly technical to the lay public or overly simple to health care providers &#8212; he deftly lays out what\u00a0many of the challenges\u00a0are in the care of both the elderly and the terminally ill. For example, how can we negotiate\u00a0the conflict between personal freedom versus\u00a0safety in our loved ones who have such a limited time to live? If 90-year-old Uncle Milton with severe congestive heart failure\u00a0wants to eat pickles, but pickles contain too much salt for his diet, should we stop him?\u00a0The recent <a href=\"http:\/\/www.pbs.org\/wgbh\/pages\/frontline\/being-mortal\/\" target=\"_blank\" rel=\"noopener noreferrer\"><em><strong>Frontline<\/strong><\/em><\/a>\u00a0about Atul (we&#8217;re on a first name basis,<strong> <a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/brush-with-greatness-atul-gawande\/2012\/08\/15\/\" target=\"_blank\" rel=\"noopener noreferrer\">brush with greatness<\/a>)<\/strong> and his book make me hope that his sensible\u00a0voice will lead to\u00a0progress\u00a0in this difficult part of health care.<\/li>\n<li>Finally, if you&#8217;re looking for a terrific podcast, check out this Radiolab piece called <strong><em><a href=\"http:\/\/www.radiolab.org\/story\/dead-reckoning\/?utm_source=local&amp;utm_medium=treatment&amp;utm_campaign=daMost&amp;utm_content=damostviewed\" target=\"_blank\" rel=\"noopener noreferrer\">Dead Reckoning.<\/a><\/em><\/strong><em>\u00a0<\/em>The first part is about surviving rabies &#8212; good stuff for ID doctors, and yes, we&#8217;re that bizarre\u00a0&#8212; but the piece\u00a0finishes in more familiar territory, dealing with medical options at the end of life. In a section called &#8220;The Bitter End&#8221;, it cites a now\u00a0famous study done of Hopkins med school graduates, demonstrating that doctors say they would\u00a0forego end-of-life treatments if they had an incurable brain disease (something akin to dementia) &#8212; a big contrast with the people interviewed on the street, most of whom want\u00a0all this stuff. The\u00a0end-of-life treatments these doctors considered are shown in the figure below:<\/li>\n<\/ul>\n<p><a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/02\/Gallo-figure-2.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter wp-image-5816\" src=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/02\/Gallo-figure-2.jpg\" alt=\"Gallo-figure-2\" width=\"585\" height=\"422\" srcset=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/02\/Gallo-figure-2.jpg 900w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/02\/Gallo-figure-2-300x217.jpg 300w\" sizes=\"auto, (max-width: 585px) 100vw, 585px\" \/><\/a><\/p>\n<p>Note the ninth one on this list &#8212; <strong><em>antibiotics<\/em> <\/strong>&#8212; and consider a scenario that no doubt will be familiar to doctors and nurses the world over, and not just to ID doctors: The patient who has metastatic cancer, or advanced dementia, or irreversible advanced heart or lung disease, and the decision has been made to withhold CPR, mechanical ventilation, tube feeding, and dialysis.<\/p>\n<p>But antibiotics? They often remain an option to the very end, frequently\u00a0in the face of other conditions with terrible prognoses and little chance for reversal. Those recurrent urinary tract infections, aspiration pneumonias, infected pressure sores, and other indignities\u00a0of our failing bodies can be treated with antibiotics (though with progressively less effect) &#8212; but to what end?<\/p>\n<p>So read the case, take the poll, then listen to the Radiolab piece.<\/p>\n<blockquote><p><em>A 94-year-old woman with advanced dementia is referred to the hospital from her nursing home because of\u00a0fever and a change in mental status. At baseline, she can sit in a chair but cannot walk, feed, or bathe herself; she can respond to simple questions, but has little spontaneous speech. She has an existing DNR order &#8212; no CPR or intubation. There have been two admissions to the hospital over the past six months\u00a0(pneumonia, urinary tract infection), after which she returned to the nursing home. In the emergency room, her evaluation is notable for a fever and somnolence. The urinalysis shows 50-100 WBC. The health care proxy, who lives in another state, is unavailable.<\/em><\/p><\/blockquote>\n<div id=\"polls-24\" class=\"wp-polls\">\n\t<form id=\"polls_form_24\" class=\"wp-polls-form\" action=\"\/index.php\" method=\"post\">\n\t\t<p style=\"display: none;\"><input type=\"hidden\" id=\"poll_24_nonce\" name=\"wp-polls-nonce\" value=\"613e5a2764\" \/><\/p>\n\t\t<p style=\"display: none;\"><input type=\"hidden\" name=\"poll_id\" value=\"24\" \/><\/p>\n\t\t<p style=\"text-align: center;\"><strong>Should antibiotics be given?<\/strong><\/p><div id=\"polls-24-ans\" class=\"wp-polls-ans\"><ul class=\"wp-polls-ul\">\n\t\t<li><input type=\"radio\" id=\"poll-answer-80\" name=\"poll_24\" value=\"80\" \/> <label for=\"poll-answer-80\">Yes -- we must do everything short of CPR and intubation.<\/label><\/li>\n\t\t<li><input type=\"radio\" id=\"poll-answer-81\" name=\"poll_24\" value=\"81\" \/> <label for=\"poll-answer-81\">No -- antibiotic treatment should be considered a futile medical intervention.<\/label><\/li>\n\t\t<\/ul><p style=\"text-align: center;\"><input type=\"button\" name=\"vote\" value=\"   Vote   \" class=\"Buttons\" onclick=\"poll_vote(24);\" \/><\/p><p style=\"text-align: center;\"><a href=\"#ViewPollResults\" onclick=\"poll_result(24); return false;\" title=\"View Results Of This Poll\">View Results<\/a><\/p><\/div>\n\t<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"<p>There&#8217;s been some truly outstanding work done recently\u00a0on\u00a0end-of-life care, and how we deal with it &#8212; or more accurately, how we typically\u00a0don&#8217;t deal with it until the very last moment, at which time often many\u00a0unfortunate decisions and\u00a0events occur. Here are three I can strongly recommend: Roz Chast&#8217;s Can&#8217;t We Talk About Something More Pleasant?\u00a0is probably [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,5,8,9],"tags":[],"class_list":["post-5815","post","type-post","status-publish","format-standard","hentry","category-health-care","category-infectious-diseases","category-patient-care","category-policy"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/5815","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=5815"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/5815\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=5815"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=5815"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=5815"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}