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Introdução: A prática de uso de antibiótico até a morte é uma prática hospitalar comum para doentes terminais em fase de fim de vida (FdV). No entanto, em muitos casos a eficácia e o benefício desta terapia é duvidosa, e o uso indiscriminado e indevidamente prolongado de antibiótico nesta população contribui para a emergência de bactérias multirresistentes (MDR). Objetivos: Determinar a prevalência de utilização de antibiótico nos últimos dias de vida de doentes com e sem doença terminal no hospital, em particular a sua classe, duração, benefícios observados e o envolvimento das equipas de Cuidados Paliativos (CP) no tratamento. Métodos: Incorporado num estudo multicêntrico, realizámos um estudo longitudinal, retrospetivo, analítico e observacional, focado na utilização de antibioterapia na amostra de 300 doentes que faleceram no hospital, nomeadamente no Serviço de Medicina (SdM) e nas unidades do Serviço de Medicina Intensiva (UCI). Resultados: No conjunto dos dois serviços, 62,6% dos doentes falecidos apresentavam condições terminais associadas a patologias crónicas avançadas. Entre os pacientes terminais que faleceram, 55,3% receberam antibióticos até à morte, frequentemente de largo espetro. No SdM, doentes terminais receberam menos antibiótico do que não-terminais (40,7 versus 56,8%), ao contrário da UCI onde essa relação era semelhante (69,2% versus 75%). A duração média de terapia antibiótica era semelhante entre os doentes terminais e não-terminais (5,2 e 5,6 dias). Uma resposta clínica positiva ao tratamento foi documentada em 12 doentes. Foi pedido consultoria à equipa dos CP a 16 doentes.(5,3%). Aproximadamente 70% dos doentes faleceram sob a decisão de Não-Resuscitação (DNR), dos quais 48,1% estavam sob antibioterapia nos últimos dias de vida. O tempo médio de tratamento foi semelhante entre os com e sem ordem de DNR. Um número considerável de doentes em FdV e sob ordem de DNR (26 doentes no SdM e 8 na UCI) recebeu antibiótico durante um período excessivamente prolongado. Discussão e Conclusão: Observámos uma elevada prevalência na prescrição de antibióticos de largo espetro nos doentes em FdV, tanto no SdM quanto na UCI. Além disso, identificámos um prolongamento excessivo na administração desses antibióticos, apesar do estado avançado da doença e da decisão prévia de DNR tomada nesta população Não pondo de parte a subdocumentação nos processos clínicos, o número escasso de doentes com melhoria clinica levanta dúvidas sobre a eficácia e os benefícios da terapia com antibióticos em muitos doentes em FdV. V Verificou-se uma participação das equipas de Cuidados Paliativos muito restrita. Uma solução para mitigar o uso indiscriminado de antibióticos em doentes em FdV, com contextos clínicos e éticos tão singulares, reside numa abordagem especializada e centrada no paciente, a qual não pode ser alcançada sem a contribuição ativa dos CP.
Introduction: The use of antibiotic until death is a common hospital practice for terminally ill patients at the end-of-life (EOL). However, in many cases, the effectiveness and benefit of this therapy are questionable, and the indiscriminate and improperly prolonged use of antibiotics in this population contributes to the emergence of multidrug-resistant bacteria (MDR). Objectives: The objective of this study was to determine the prevalence of antibiotic use in the last days of life for both patients with and without terminal illnesses in a hospital setting, including its class, duration, observed benefits, and the involvement of Palliative Care (PC) teams in the treatment. Method Embedded within a multicenter study, we conducted a longitudinal, retrospective, analytical, and observational study focused on the use of antibiotic therapy in 300 patients who died in the hospital, specifically in the Internal Medical Department (IMD) and the Intensive Care Department (ICU). Results: In both departments, 62.6% of deceased patients had terminal conditions associated with advanced chronic diseases. Among terminal patients who died, 55.3% received antibiotics until death, many of which had broadspectrum activity. In the IMD, terminal patients received fewer antibiotics than non-terminal patients (40.7% versus 56.8%), unlike the ICU where this relationship was similar (69.2% versus 75%). The average duration of antibiotic therapy was alike between terminal and non-terminal patients (5.2 and 5.6 days). A positive clinical response to treatment was documented in 12 patients. Consultation was requested from the PC team for 16 patients (5.3%). Approximately 70% of patients died with a Do Not Resuscitate (DNR) order in effect, of which 48.1% were under antibiotic therapy in the last days of life. The average duration of treatment was comparable between patients with and without DNR orders. A considerable number of EOL patients under DNR orders (26 patients in the SdM and 8 in the ICU) received antibiotics for an excessively prolonged period. Discussion and Conclusion: We observed a high prevalence of broad-spectrum antibiotic prescription in EOL patients, both in the IMD and the ICU. Furthermore, we observed an unnecessary extension in the administration of these antibiotics, despite the advanced state of the disease and the prior DNR decision made in this population. Notwithstanding potential underdocumentation in clinical records, the limited number of patients with clinical improvement raises doubts about the efficacy and benefits of antibiotic therapy in many EOL patients. VIII There was limited participation of the PC teams. A solution to mitigate the indiscriminate use of antibiotics in EOL patients, given their unique clinical and ethical contexts, lies in a specialized and patient-centered approach, which cannot be achieved without the active involvement of PC.
Introduction: The use of antibiotic until death is a common hospital practice for terminally ill patients at the end-of-life (EOL). However, in many cases, the effectiveness and benefit of this therapy are questionable, and the indiscriminate and improperly prolonged use of antibiotics in this population contributes to the emergence of multidrug-resistant bacteria (MDR). Objectives: The objective of this study was to determine the prevalence of antibiotic use in the last days of life for both patients with and without terminal illnesses in a hospital setting, including its class, duration, observed benefits, and the involvement of Palliative Care (PC) teams in the treatment. Method Embedded within a multicenter study, we conducted a longitudinal, retrospective, analytical, and observational study focused on the use of antibiotic therapy in 300 patients who died in the hospital, specifically in the Internal Medical Department (IMD) and the Intensive Care Department (ICU). Results: In both departments, 62.6% of deceased patients had terminal conditions associated with advanced chronic diseases. Among terminal patients who died, 55.3% received antibiotics until death, many of which had broadspectrum activity. In the IMD, terminal patients received fewer antibiotics than non-terminal patients (40.7% versus 56.8%), unlike the ICU where this relationship was similar (69.2% versus 75%). The average duration of antibiotic therapy was alike between terminal and non-terminal patients (5.2 and 5.6 days). A positive clinical response to treatment was documented in 12 patients. Consultation was requested from the PC team for 16 patients (5.3%). Approximately 70% of patients died with a Do Not Resuscitate (DNR) order in effect, of which 48.1% were under antibiotic therapy in the last days of life. The average duration of treatment was comparable between patients with and without DNR orders. A considerable number of EOL patients under DNR orders (26 patients in the SdM and 8 in the ICU) received antibiotics for an excessively prolonged period. Discussion and Conclusion: We observed a high prevalence of broad-spectrum antibiotic prescription in EOL patients, both in the IMD and the ICU. Furthermore, we observed an unnecessary extension in the administration of these antibiotics, despite the advanced state of the disease and the prior DNR decision made in this population. Notwithstanding potential underdocumentation in clinical records, the limited number of patients with clinical improvement raises doubts about the efficacy and benefits of antibiotic therapy in many EOL patients. VIII There was limited participation of the PC teams. A solution to mitigate the indiscriminate use of antibiotics in EOL patients, given their unique clinical and ethical contexts, lies in a specialized and patient-centered approach, which cannot be achieved without the active involvement of PC.
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Keywords
Cuidados paliativos Cuidados em fim-de-vida Tratamento com antibiótico Bactérias multirresistentes Palliative care End-of-life care Antibiotic therapy Multidrug-resistant bacteria