Digitally Enabling High-Touch and High-Impact Antimicrobial Use in End-of-Life Care

During the COVID-19 pandemic, our team demonstrated the ability to blend high-tech capabilities with ethical commitments to provide quality care.1 As attention shifts from COVID-19 to antimicrobial resistance (AMR), a long-standing global health threat, we emphasize the importance of addressing AMR in end-of-life (EoL) care. Utilizing digital tools can enhance both the personal touch and the effectiveness of care in the face of the AMR challenge. The challenge of AMR occurs when pathogens no longer respond to antimicrobials such as antibiotics and is among the top 10 global public health threats today. GBD 2021 Antimicrobial Resistance Collaborators2 forecast that an estimated 1.91 million deaths attributable to AMR and 8.22 million deaths associated with AMR could occur globally in 2050. Despite the magnitude of this threat, countermeasures to AMR have been fragmented and uneven across a diverse range of interested parties, including institutional and state actors. AMR, particularly antibiotic resistance, poses a complex challenge for multiple reasons. First, the link between antibiotic use and AMR development may not be immediately obvious, spanning different knowledge domains. Second, unlike the rapid impact of events such as the COVID-19 pandemic, AMR escalates gradually, making it challenging to prioritize effectively. Lastly, the limited discovery of new antibiotics has led to a shift toward emphasizing the judicious use of existing ones to combat AMR. Earlier this year, the World Health Organization outlined a global research agenda on AMR in human health, focusing on infections caused by bacterial priority pathogens. With 40 research priority areas for both adults and children worldwide, the World Health Organization aims to expand knowledge on AMR by 2030. However, EoL antimicrobial use in healthcare settings remains a concern, as it can lead to the development and spread of multidrug-resistant organisms. As Rosa et al explain, the complexity of antimicrobial prescribing is further complicated in advanced serious illness and EoL care due to various factors.3 For example, the use of antibiotics such as penicillins, macrolides, fluoroquinolones, and cephalosporins in treating common infections may have unintended adverse effects such as Clostridium difficile infection. Antimicrobial therapy at the EoL may profoundly impact patients’ well-being and respect for their dignity, as well as on health systems and their ability to respond effectively to a range of infections. Where patients are concerned, antimicrobial use and deprescribing at the EoL should be discussed with them and their significant others, where appropriate. Infections are common complications experienced by terminally ill patients and should not be perceived as an unnatural cause of death. The potential drawbacks of antimicrobial use should also be discussed to help patients and their significant others understand the potential futility of further antimicrobial treatment and inconsistency with patients’ wishes and preferences. Where health systems are concerned, wise use of antimicrobials helps to safeguard its ability to respond effectively to infection, to control healthcare costs, and to advance person-centered care. In health systems such as Hong Kong and Australia, antimicrobials are considered life-sustaining treatment (LST) for potentially life-threatening infections. Decision-making regarding EoL antimicrobial prescribing should involve patients and healthcare providers through advanced care planning. Legislation such as the Advance Decision on Life-Sustaining Treatment Ordinance (Cap. 651) in Hong Kong and the Medical Treatment Planning and Decisions Act in Victoria, Australia, formalize procedures for withholding or withdrawing LST. Although legal instruments such as advance medical directives and advance care directives allow individuals to plan for LST decisions, their impact on EoL antimicrobial use and discussions remains uncertain. Based on our unpublished data4 from 2017 to 2023 in Hong Kong, we have observed that 80% to 90% of patients received antibiotics shortly before death. Specifically, among patients with a prior cancer diagnosis, 82% of them received antibiotics within 7 days before death during their in-hospital stay. This highlights the concerning trend of patients continuing to receive antibiotic treatment even during EoL care. Studies in Australia highlight the limited availability of data on antimicrobial use in hospital EoL settings5 and emphasize the need for such data for the promotion of advanced care planning with a focus on antibiotic use. However, there are also exceptions when palliative antibiotics may be prescribed to treat pain and dysuria from urinary tract infections.6 Digital health technology has shown potential to enhance diagnosis, treatment, and surveillance of bacterial infections, aiding in the prevention of AMR.7 Tools such as clinical decision support systems, mobile health apps, artificial intelligence, and wearable devices can improve communication for comprehensive EoL care tailored to individual needs and preferences. In Hong Kong, electronic advance medical directives will be integrated into the “eHealth” digital system.8 High digital capacity can assist in assessing risks and benefits of decisions, promoting timely, person-centered discussions on antibiotic therapy initiation or cessation with consideration of adverse effects and AMR risks. Recent studies have highlighted challenges in the effective use of digital tools, such as suboptimal data systems, infrastructure limitations,9 and regulatory fragmentation.10 These obstacles also impact the integration of digital tools in EoL care. The Just Transitions for AMR Working Group addresses these challenges with a view to realize a future with equitable and sustainable antimicrobial use by leveraging digital experiences and capabilities.11 Although digital technology cannot solve the complex issue of AMR, it can enhance personalized antimicrobial care aligned with patient preferences and optimize outcomes. In conclusion, the integration of digital health technology in EoL care presents an opportunity to address the challenge of AMR. By leveraging tools such as clinical decision support systems and mobile health apps, healthcare providers can enhance communication, promote timely discussions on antibiotic therapy, and tailor care to individual needs while considering AMR risks to improve antimicrobial stewardship. With all best wishes, Calvin Wai-Loon Ho, JSD, FRSPHFaculty of Law, Monash University, Melbourne, Australia; and Centre for Medical Ethics and Law The University of Hong KongCeline Sze Ling Chui, PhD, FRSPHSchool of Nursing, Li Ka Shing Faculty of Medicine The University of Hong KongChia-Chin Lin, PhD, RN, FAANEditorial Board Member, Cancer Nursing School of Nursing, Li Ka Shing Faculty of Medicine The University of Hong Kong