Reducing Antimicrobial Use at the End of Life—When to Open the Door

In the best-case scenario, clinical teams who care for patients with terminal illnesses engage in shared decision-making and allow for patient autonomy as much as possible while ensuring transparency about risks and benefits.Given how common infectious complications are at the end of life (often leading to the terminal event), the use of antimicrobial therapies should be included among the many decisions shared, 1 but such decisions are often deferred exclusively to the treating teams.Kim and colleagues 2 explore antimicrobial use at different stages at the end of life among patients with terminal cancer using data from the South Korean National Health Insurance Service database.Remarkably, they reviewed data on 515 366 decedents with a history of solid or hematologic cancers.The use of broad-spectrum antibiotics was highest in the second period (3 months to 1 month prior to death).Those with hematologic and biliary tract cancers were more likely to receive broad-spectrum antibiotics in this period than those with other cancers.In clinical practice, this finding is unsurprising given the nature of the diseases, as neutropenic fevers are common in hematologic cancers (with guidelines suggesting empiric antipseudomonal coverage), and recurrent obstructions are common in biliary tract cancers, which may result in several antimicrobial courses and the subsequent development of progressive drug resistance.Total consumption of antibiotics peaked in the third period (1 month to 2 weeks prior to death). 2 The authors suggest that during this period, functional decline is much more rapid; in theory, this means the prospect of death may become more evident.In the early days of the HIV epidemic, when HIV was considered a terminal illness, infectious disease clinicians used the Karnofsky Performance Scale to determine 1 of 3 things: whether a person should receive a therapy, whether therapy should