111: StAR: Use of antimicrobials at the end of life

Sara Dong: 00:00:03

Hi everyone, welcome to Febrile, a cultured podcast about all things infectious disease.

Sara Dong: 00:00:08

We use consult questions to dive into ID clinical reasoning, diagnostics, and antimicrobial management.

Sara Dong: 00:00:14

I'm Sara Dong, your host and a MedPeds ID doc.

Sara Dong: 00:00:18

I am excited to be joined by three guests today.

Sara Dong: 00:00:21

First up, I have Dr.

Sara Dong: 00:00:23

Christine Pham.

Sara Dong: 00:00:24

Christine is one of the Antimicrobial Stewardship and ID Pharmacy Leads at UCLA.

Sara Dong: 00:00:29

She is continuously engaged in University of California wide antimicrobial stewardship and educational outreach initiatives.

Sara Dong: 00:00:36

She also served as the 2021 2022 lead of the UC System wide ASP Collaborative.

Christine Pham: 00:00:43

Hi, this is Christine.

Christine Pham: 00:00:45

I'm excited to be here and sit with you guys to talk about our topic today.

Sara Dong: 00:00:49

Next, I have Dr.

Sara Dong: 00:00:50

Daisuke Furukawa.

Sara Dong: 00:00:52

Daisuke is a clinical assistant professor in the Division of Infectious Diseases at Stanford University.

Sara Dong: 00:00:58

He has a passion for antimicrobial stewardship, and his current clinical and research focuses are primarily in orthopedic infectious diseases.

Daisuke Furukawa: 00:01:06

Hi, I'm Daisuke.

Daisuke Furukawa: 00:01:07

Thanks for having me.

Daisuke Furukawa: 00:01:08

Excited to be here.

Sara Dong: 00:01:09

Dr.

Sara Dong: 00:01:10

Daniel, or Dan Carlin, is a Los Angeles native trained in internal medicine, pediatrics, and palliative care.

Sara Dong: 00:01:17

He's an assistant clinical professor in palliative care at UCLA.

Sara Dong: 00:01:20

He's passionate about all things communication related and wishes he could better remember all those antibiotic regimens from residency.

Dan Carlin: 00:01:27

Hey there, I'm Dan Carlin.

Dan Carlin: 00:01:29

It's really great to be here.

Dan Carlin: 00:01:30

Thank you for having us.

Sara Dong: 00:01:32

As everyone's favorite cultured podcast, we like to ask if you'd be willing to share a little piece of culture, basically just something non medical that you have enjoyed recently or that brings you happiness.

Sara Dong: 00:01:43

I'll start with you, Daisuke.

Daisuke Furukawa: 00:01:45

I have a almost three year old son, so he is obviously my greatest joy.

Daisuke Furukawa: 00:01:51

Even through the highs and lows of the terrible twos, it brings me great joy.

Sara Dong: 00:01:55

What about you, Christine?

Christine Pham: 00:01:56

So recently, I enjoyed, I mean, there's downstream effects of having, when you read Reddit threads, but I was helping my sister negotiate the price of a new car down.

Christine Pham: 00:02:10

And we actually were looking at subreddit threads that were really helpful and informative to know what customers got out the door.

Christine Pham: 00:02:20

for different cars in different states so that we felt good about the price that we were able to negotiate down to.

Christine Pham: 00:02:26

So that was something that was a recent experience and I haven't really appreciated Reddit really fully until that was what I enjoyed most recently.

Sara Dong: 00:02:36

Yeah, Reddit is definitely its own culture and world.

Christine Pham: 00:02:40

It is.

Christine Pham: 00:02:41

It is.

Sara Dong: 00:02:43

Awesome.

Sara Dong: 00:02:43

And what about you, Dan?

Dan Carlin: 00:02:45

I also have two young kids, so our house is constantly awash in Bluey, which is amazing and I highly recommend it to everyone.

Dan Carlin: 00:02:52

The one thing I've been reading is a book called How to Be Perfect, The Correct Answer to Every Moral Question by Michael Schur.

Dan Carlin: 00:03:00

He's the guy that wrote The Good Place and was involved in The Office, and it's just this dive into ethics, but told through a very comedic lens and extremely relatable.

Dan Carlin: 00:03:10

So I highly, highly recommend it.

Sara Dong: 00:03:12

Sounds good.

Sara Dong: 00:03:13

I'm going to have to add that to my list.

Sara Dong: 00:03:15

Well, thank you guys for being here.

Sara Dong: 00:03:18

You know, we're welcoming everyone to another STAR episode, which is focused on these State of the Art Reviews from the CID Journal.

Sara Dong: 00:03:25

And you and your colleagues have created an article that's wonderful about thinking and approaching the use of antimicrobials at the end of life.

Sara Dong: 00:03:34

And so we are going to chat about some clinical scenarios in the episode, but I actually like to start by just opening the floor to ask if you might give an introduction to the topic, goals you had for the article or other major considerations you had as you set out to make a review like this.

Dan Carlin: 00:03:52

Yeah, absolutely.

Dan Carlin: 00:03:53

To give a little context to this, rewind all the way back to pre pandemic 2018, 2017, I think, where, in the hallways of Santa Monica Hospital, where I was a palliative care physician, Daisuke was a fellow at the time in ID.

Dan Carlin: 00:04:10

This came out of conversations with all of us together, including Dr.

Dan Carlin: 00:04:17

Tara Vijayan, our fantastic ID colleague, just about the moral distress that we felt around a lot of patients that we were taking care of, where it felt like inappropriate or non beneficial antibiotic use in the context of someone with a really poor prognosis or where we weren't talking about goals of care.

Dan Carlin: 00:04:39

And those initial hallway moments of airing our moral distress actually led into just these ongoing conversations about how do we bring the palliative lens into infectious disease and really try to have some strategies to deal with what we're seeing on a regular basis to better approach this.

Dan Carlin: 00:04:58

And so that's actually where it came out of, and it just evolved and evolved over time into greater collaboration between our groups, and then ultimately this article.

Sara Dong: 00:05:08

Yeah, that's awesome.

Sara Dong: 00:05:09

And today, along with a lot of Febrile episodes, we're going to use the scenario of a patient to talk through what you have, at least, started to talk about in the article and that many of us experience when we're on consult service.

Sara Dong: 00:05:21

And so a scenario of a patient with a malignant obstruction that leads to recurrent abscesses.

Sara Dong: 00:05:26

And so I'll give us a little intro to our patient.

Sara Dong: 00:05:29

She is a 67 year old woman with newly diagnosed unresectable cholangiocarcinoma who begins chemotherapy.

Sara Dong: 00:05:38

She subsequently develops fever, loss of appetite and right upper quadrant abdominal pain resulting in hospital admission.

Sara Dong: 00:05:46

On admission, she started on piperacillin tazobactam, and a CT scan reveals several rim enhancing fluid collections in her liver.

Sara Dong: 00:05:54

A percutaneous biliary drain is placed, and fluid from this procedure grows at Enterobacter cloacae complex.

Sara Dong: 00:06:00

Her oncology team is preparing to discharge her home.

Sara Dong: 00:06:04

We often get called in dilemmas like this, uh, such as when source control might not be really feasible, how might we, as the ID team, help with conversations about discussing the infection and treatment plan in something like this situation?

Daisuke Furukawa: 00:06:19

ID doctors can really help with setting expectations about not only the the treatment plan, but also in terms of the long-term outcomes and natural history of an infection like this, so this is clearly a source control issue.

Daisuke Furukawa: 00:06:34

Infection eradication is extremely challenging, if not impossible, and there's a very high likelihood of infection recurrence or persistence.

Daisuke Furukawa: 00:06:43

What ends up happening is we go through this downward spiral of giving antibiotics, infection comes back, oftentimes with a much more resistant organism, so we have to resort to broader spectrum antibiotics.

Daisuke Furukawa: 00:06:57

But the infection still comes back, and then we just kind of go through this cycle of infection, antibiotics, infection, antibiotics.

Daisuke Furukawa: 00:07:02

As ID doctors, I think we really have a good understanding of this process very well, so we can help patients understand the limitations of antibiotics, but also to help them understand that infection, in this case, is more of a like a symptom of the underlying disease.

Daisuke Furukawa: 00:07:21

In this case, cancer, rather than it being like an independent disease process.

Daisuke Furukawa: 00:07:24

So I think as an ID doctor, we can really help patients understand the infection in the context of the greater underlying disease process.

Daisuke Furukawa: 00:07:33

I think that's really important.

Daisuke Furukawa: 00:07:35

A couple of other things that I want to point out is that I think conversations like this, we should do it early.

Daisuke Furukawa: 00:07:40

So you know, don't wait until the fourth, fifth, sixth admission the patient experiences.

Daisuke Furukawa: 00:07:46

You can start having these conversations very early on.

Daisuke Furukawa: 00:07:49

And I think that's just better for the patient, and it'll also help us build better trust and better relationship with the patient as well.

Daisuke Furukawa: 00:07:56

And then lastly, I think another important point is also to have a similar conversation with other providers as well.

Daisuke Furukawa: 00:08:03

So in this case, it'll be like the oncologist, or even the surgeons, or the other proceduralists, even the outpatient primary care doctor.

Daisuke Furukawa: 00:08:11

So that we can just kind of all be in the same page and deliver the same message to the patient.

Dan Carlin: 00:08:16

And going off that, Daisuke, I think there's like this really key piece of what do we define as incurable?

Dan Carlin: 00:08:22

What do we define as a process that is just not going to go away on its own and we will constantly be dealing with it?

Dan Carlin: 00:08:29

And I think It's rare that we actually give that name to an infectious process where we can explain it in a way that a patient's going to understand.

Dan Carlin: 00:08:38

This is going to be for the remainder of their life, something that will drastically change their trajectory.

Dan Carlin: 00:08:43

And having that be clear, having that be extremely explicit is really important.

Christine Pham: 00:08:49

Well, I think in this patient case, when you have something that's unresectable, when you have lack of source control, that's where the communication needs to be transparent to the patient and to the providers that there's going to be a high probability of recurrence.

Christine Pham: 00:09:06

I mean, it's going to be hard to pivot and tell the patient that at some point this is going to potentially be incurable, but there is going to be a high risk and high likelihood of that.

Christine Pham: 00:09:14

And when the providers are comfortable doing these early conversations, it's going to be challenging.

Christine Pham: 00:09:21

Usually with the first episode, and maybe even the second episode, everyone's usually optimistic as to whether we even should broach that subject, but it becomes clear when they have a poorer and poorer prognosis or they're becoming readmitted.

Christine Pham: 00:09:36

To define that point is actually really challenging for all providers.

Christine Pham: 00:09:40

Infectious disease physicians would be a good point of access or contact to actually be able to make that more transparent for everybody.

Sara Dong: 00:09:52

And just like you said about talking to the whole team and making sure that everyone is communicating that same message.

Sara Dong: 00:09:58

I think in the beginning, that's when it is really challenging.

Sara Dong: 00:10:01

That sometimes the patients receive information of a huge spectrum of where this infection will ultimately end up.

Sara Dong: 00:10:10

Well, this patient in this scenario is discharged home with cefepime, but develops distressing anasarca.

Sara Dong: 00:10:18

She follows up at a visit with her ID physician and a switch to oral trimethoprim sulfamethoxazole, but develops severe nausea and vomiting, leading to readmission for dehydration.

Sara Dong: 00:10:31

During this hospitalization, her biliary drain is replaced.

Sara Dong: 00:10:34

There are two additional drains inserted.

Sara Dong: 00:10:37

The cultures from these drains are growing now drug resistant E.

Sara Dong: 00:10:41

coli.

Sara Dong: 00:10:42

Due to resistance and intolerance, the ID team identifies no appropriate oral antibiotic options.

Sara Dong: 00:10:48

So this time, she's discharged with ertapenem with a plan for a close follow up in clinic.

Sara Dong: 00:10:53

Over the next several months, antibiotics are stopped intermittently due to ongoing side effects.

Sara Dong: 00:10:58

You know, she continues to have these hospitalizations that we talked about, uh, with recurrent abscesses and consultants from GI, IR, and general surgery are agreeing that definitive source control is not possible.

Sara Dong: 00:11:11

So we started to talk about this conversation a little bit, but how do we address antibiotic use in a context like this?

Christine Pham: 00:11:17

So I'll explain.

Christine Pham: 00:11:18

Span a little bit more as to why we wanted to focus on the patient doing rounds and rounds of different antimicrobials.

Christine Pham: 00:11:27

It's based on the assumption that a lot of patients and a lot of providers think that antimicrobials are a low risk intervention, but in reality, all antimicrobials have some side effects, may have a downstream effect, and this patient had trialed bactrim, cefepime, and ertapenem, which were becoming

Christine Pham: 00:11:47

more broad spectrum antimicrobials, and then we're approaching to a point where we're no longer curing it and just trying to control the infection.

Christine Pham: 00:11:56

That needs to be communicated that we're reaching to a point where there's going to be less benign drugs and it's going to be contingent on whether the patient is tolerating it and whether there will be emerging drug resistance.

Christine Pham: 00:12:11

That also needs to be communicated to the patient, patient's family, and also to the providers that antimicrobials are not something that can be considered as a low risk that you can potentially give for an indefinite amount of time or undefined duration.

Dan Carlin: 00:12:30

And that's why this feels like a transition point, honestly, is that whenever we're getting to a point that someone is going on long term IV antibiotics, where there's suppressive antibiotics coming in, they've failed multiple lines, we're getting to a point of resistance, this is where we actually really need to define that we're in a different place.

Dan Carlin: 00:12:47

And in the same way that the oncologist would say, well, we're switching from curative treatment to palliative treatment.

Dan Carlin: 00:12:53

It's time to talk about goals of care.

Dan Carlin: 00:12:55

I think that's what's coming up in this as well, is that we actually need to use this as a hallmark of, all right, let's talk about where this goes if we keep going down this road.

Dan Carlin: 00:13:05

And that's kind of why we wanted to introduce the, the palliative lens and the structure of how to have these conversations around goals of care from an earlier perspective and exploring what a person's goals around this infection might be.

Dan Carlin: 00:13:19

Now, in our heads, we always play out this conversation of like, they're going to ask me to just treat the infection, right?

Dan Carlin: 00:13:24

That is going to feel like the only goal that they're going to give me.

Dan Carlin: 00:13:28

We really want to open it up in terms of larger range of values that might be important to them and especially what their worries are about the future.

Dan Carlin: 00:13:36

What we brought in and what we talked about in the article is this framework called the REMAP that comes from Vital Talk, which is this really large organization that does a lot of great work in communication and palliative care and oncology about how to structure this conversation.

Dan Carlin: 00:13:51

And REMAP stands for reframe, expect emotion, map out patient goals, align with those goals and propose a plan.

Dan Carlin: 00:14:02

In this kind of context, it really goes into kind of breaking a little bit of bad news.

Dan Carlin: 00:14:08

Hey, let's reframe the situation that we're in.

Dan Carlin: 00:14:10

We've been able to control this only with oral antibiotics so far.

Dan Carlin: 00:14:13

We're in a different place right now.

Dan Carlin: 00:14:15

We're going to have a harder and harder time controlling where this goes, that might be met with emotion that might not be.

Dan Carlin: 00:14:22

We'll talk a little bit more later about how to respond to those emotions if we need to.

Dan Carlin: 00:14:27

But really helping break the news that this is getting more incurable and that this might actually be a life limiting illness independent of the cancer itself.

Dan Carlin: 00:14:36

Um, and if that can be communicated, that might actually bring up a lot of emotion for someone.

Dan Carlin: 00:14:41

You know, we then map out values, meaning, what's important to you?

Dan Carlin: 00:14:44

What do you want to prioritize when we think about treating this infection?

Dan Carlin: 00:14:47

Is it only going to be about using the strongest medicine regardless if you're on an IV course for six weeks at a time?

Dan Carlin: 00:14:55

Is this going to be more about, are there any side effects that are intolerable to you?

Dan Carlin: 00:15:01

What do you want to really focus on and make sure that we're being mindful of as we think of your treatment?

Dan Carlin: 00:15:07

We align with those and really show that we respect those values, that they're informing the choices that we make as physicians, and then we propose a plan.

Dan Carlin: 00:15:15

And that might be something where we say, you know, planning out the future, we might need to talk about a point where these procedures and antibiotics are not actually helping you live the quality of life that you want to have.

Dan Carlin: 00:15:27

We need to think about what do we do when we reach that point, and it's not benefiting you as much.

Dan Carlin: 00:15:33

That's kind of what we want to sketch out.

Dan Carlin: 00:15:35

And in the article, it goes into a bit more depth and tries to provide some phrasing around it.

Dan Carlin: 00:15:39

But really, it's about taking the structure that we know works in a palliative kind of context and saying, when infectious processes become incurable and become life limiting, how can we start to have goals of care discussions around that?

Sara Dong: 00:15:56

This patient becomes confused and drowsy at home, is again readmitted for AKI and fluid refractory hypotension.

Sara Dong: 00:16:04

She is transferred to the ICU for pressor support and management of septic shock.

Sara Dong: 00:16:09

In this setting, the ICU team has started meropenem and vancomycin empirically.

Sara Dong: 00:16:14

Blood cultures now grow Candida species and the ID team recommends adding caspofungin.

Sara Dong: 00:16:20

Per the oncology team, her chemotherapy is on hold until the candidemia is appropriately treated.

Sara Dong: 00:16:26

Really, they're thinking that it's unlikely to be continued due to her overall physical deconditioning and comorbidities.

Sara Dong: 00:16:33

The palliative care is involved and the patient agrees to transition to home with hospice care if the patient is stable for discharge.

Sara Dong: 00:16:43

They request to continue the same antibiotics while on hospice.

Sara Dong: 00:16:48

Understanding the benefits of antimicrobial therapy at the end of life is so challenging.

Sara Dong: 00:16:53

And I think people have very different expectations.

Sara Dong: 00:16:57

I was wondering if we could talk about that a little bit, you know, how do we navigate this in a patient centered way where we are aligning with what they'd hope for, but trying to provide the best advice about how truly useful antibiotics are at this point.

Dan Carlin: 00:17:12

Really, we're talking about a situation that I, and again, speaking as a palliative doc with a lot of fantastic ID colleagues, many, many, many ID physicians are facing this.

Dan Carlin: 00:17:23

When antibiotics are started in a late stage ICU situation, they're sort of bundled with an entire septic shock presentation.

Dan Carlin: 00:17:34

And we know that it's probably not going to change the trajectory of their course.

Dan Carlin: 00:17:40

It's going to get added on and probably not taken off in a reasonable time frame when the infection isn't really driving the picture anymore.

Dan Carlin: 00:17:48

But it's just going to be sort of part of the scenery, meaning like we, we just have to have it on and it's got to stay on and it's, we're going to breed some resistance out of that.

Dan Carlin: 00:17:57

And that's really challenging.

Dan Carlin: 00:17:58

And we want to, we want to find ways that antibiotics are in the service of larger goals, not that they're just started and continued indefinitely and the ways that we can think of antibiotics and explain this to patients and their families in a bit of a different way can really change the way that we are using them.

Dan Carlin: 00:18:17

You know, REMAP still really applies here where if we need to have larger discussions about an end of life infectious process, we can really propose that and we, we provide language that's a bit different for this timeframe, about how we're concerned that we might be getting closer to the end of life, and how we might need to explore what their values are.

Dan Carlin: 00:18:37

One of the key questions that comes up all the time is when we have patients on IV antibiotics that are started, let's say, for a pneumonia or sepsis, the person stabilizes, that patient is not able to take anything oral.

Dan Carlin: 00:18:53

And families ask to continue IV antibiotics at home while on hospice.

Dan Carlin: 00:19:00

We know that that's probably not going to change their overall course of their level of comfort.

Dan Carlin: 00:19:06

It's not going to really improve their sense of well being while at home.

Dan Carlin: 00:19:10

They're probably not even going to lengthen the amount of time that they have, if it were to be continued at home, it's really just going to kind of cause additional cost.

Dan Carlin: 00:19:19

And additional logistical challenges.

Dan Carlin: 00:19:21

And in many cases, when the hospices aren't able to provide that antibiotic, it kind of leads to delays.

Dan Carlin: 00:19:27

And, and I've had far too many patients who, even though the stated goal was to return home, never make it home and never have that meaningful time with their family because of wanting to continue or feeling the need to continue IV antibiotics.

Dan Carlin: 00:19:41

So we really want to provide for there to be ways where we explore Are we trying aggressive care for the prolongation of life?

Dan Carlin: 00:19:52

Are we focusing more on comfort?

Dan Carlin: 00:19:55

Or are we looking at a different mixture of values for trying to maximize a particular priority?

Dan Carlin: 00:20:01

Like, let's say, meaningful time, alert and awake, and interacting with family.

Dan Carlin: 00:20:06

And where are we in between that, and what goals can we have to guide us about how we direct antibiotic treatment?

Sara Dong: 00:20:12

And another scenario that kind of aligns with what we're talking about and that I've certainly encountered is when the medical team, the patient, and their caregivers or family are faced with a uncertain but likely poor prognosis, they're still deciding if recommended invasive intervention is the right fit for what they would desire.

Sara Dong: 00:20:35

And so you discuss what you termed as time limited trials in your paper.

Sara Dong: 00:20:39

And I was wondering if we could talk about that.

Sara Dong: 00:20:41

You know what components, if we are talking about something like a time limited trial, are important to make something that is well balanced, where we're, again, providing satisfaction that we're trying to exhaust all the interventions while also reducing the likelihood of inappropriate or sort of prolonged antibiotic courses.

Christine Pham: 00:21:01

Time limited trials is an effective strategy that any provider can pull out of the toolbox, and it's for the family who wants to exhaust all your options but still minimize the downstream effects of indefinite or undefined durations of antimicrobials.

Christine Pham: 00:21:20

So there's several elements to it.

Christine Pham: 00:21:22

It requires that one, you assess and define what the patient's preferences are for goals of care.

Christine Pham: 00:21:30

And then you have a predefined duration with predetermined clinical parameters that are objective so that you can measure them by and that is also communicated to the patient or patient's family.

Christine Pham: 00:21:43

And then the last component really needs to be where there needs to be follow up and reassessment and re evaluation of whether or not there was improvement or lack thereof for that specified duration.

Christine Pham: 00:21:56

And it allows the patient and the provider to be able to, as a compromise, to see whether or not to assess prognosis.

Christine Pham: 00:22:05

And then it gives you also validation whether or not antimicrobials is helping or not.

Christine Pham: 00:22:11

So I think it's a good compromise in, especially for those families who are not ready to withdraw or discontinue antibiotics completely.

Christine Pham: 00:22:21

So this is maybe the one of the more effective strategies.

Christine Pham: 00:22:25

It's been studied in ICU settings where it showed that if you were to do more formal meetings with the families and patient and follow up, the patients generally do have less aggressive ICU interventions where there might be minimal benefit.

Christine Pham: 00:22:42

So I think this is a good strategy to use in this type of setting.

Sara Dong: 00:22:47

I thought it was really helpful actually that in that box in your paper, you put a suggestion of two to three days for presumed bacterial fungal sepsis.

Sara Dong: 00:22:56

Because I think picking that duration with the team sometimes is, is hard.

Sara Dong: 00:23:00

I'm like, where do you start?

Sara Dong: 00:23:01

And what do you suggest?

Sara Dong: 00:23:02

So I actually thought that was quite useful.

Sara Dong: 00:23:04

I found that sometimes those shorter durations are harder to get everyone on board with, but I think is what we should be aiming for

Dan Carlin: 00:23:12

because so often, you, you know, if it's really making a difference and you're really quite aware early on, if you're seeing those signs of improvement.

Sara Dong: 00:23:20

Yeah.

Sara Dong: 00:23:21

And it ends up sort of being, uh, I feel like negotiation is not the right word, but in some ways that's kind of what you're doing.

Sara Dong: 00:23:28

We started talking about this as well earlier, but these conversations about serious illness are obviously intertwined with really complex emotions, an individual's cultural experiences, and that's really for everyone involved.

Sara Dong: 00:23:42

Us as a medical team, the patients, their family members, I really appreciated how you walked through a lot of the examples of these emotions like guilt and indecision.

Sara Dong: 00:23:52

And I know that we can't cover all of that in this short podcast episode, but I was wondering if you could maybe talk just a little bit about some of these emotions and how we could be better prepared to respond to them.

Dan Carlin: 00:24:03

Yeah, welcome.

Dan Carlin: 00:24:04

I welcome ID colleagues to what the palliative folks do all day, is just deal with complex emotions all the time.

Dan Carlin: 00:24:12

If I were to point to a couple of things there, I think one of the biggest reasons why we get into such challenging situations at the end of life is that we're really dealing with what feel like informational or cognitive questions or, or decisions.

Dan Carlin: 00:24:29

Like, yes, I want antibiotics.

Dan Carlin: 00:24:31

Yes, I want, or even like in the cases of like, yes, I want dialysis.

Dan Carlin: 00:24:35

When really those are emotional decisions.

Dan Carlin: 00:24:37

That's perhaps the, the, to crystallize so much of what we talk about in the article, that's what comes at the core.

Dan Carlin: 00:24:44

Is that many times these are actually driven by emotion and not by a perhaps rational sense of this is the best treatment for my loved one at the very end of life.

Dan Carlin: 00:24:55

It's this a sense of obligation or guilt if I don't treat them with antibiotics.

Dan Carlin: 00:25:00

And I think when we pick up on that, when we are really hearing from families or patients that there's a sense of obligation to continue antibiotics as a feeling of needing to do everything, that we sometimes feel like they're rationally weighing everything.

Dan Carlin: 00:25:19

They are rationally deciding that antibiotics are the best intervention for the loved one in this moment.

Dan Carlin: 00:25:25

When in reality, they're probably coming from a place of, I don't want to fail them, or I want to give them every opportunity to continue thriving.

Dan Carlin: 00:25:32

That's where, whenever possible, if we can intervene on the emotion or sort of pick up on that, this is an emotional issue going on and, and provide support in that way, it really does help to avoid a lot of the situations that we don't want to be in.

Dan Carlin: 00:25:47

You know, guilt in particular is one of those where we can talk about just affirming everything that they've done for their loved one, trying to support them through an illness, advocating for them, trying to honor all of their wishes, but also really explaining why certain

Dan Carlin: 00:26:02

interventions might only make the situation worse and relieving them from a sense of obligation in terms of having to provide that intervention.

Dan Carlin: 00:26:11

So, we threw in some language there that not wanting them to feel that they have a, a, a deep obligation to keep doing treatments that they know aren't going to provide benefit.

Dan Carlin: 00:26:23

And, and keeping a focus on the things that we can achieve that are more important, whether those are medical things or personal things.

Dan Carlin: 00:26:31

If I could have everyone just read one table in any specialty, in any context, it's that table of, comes from the Quill article, the potential underlying meanings of do everything.

Dan Carlin: 00:26:44

It is the, the article that I always go back to, if ever anyone tells me that they're struggling with managing end of life situations, I just tell them to read this article.

Dan Carlin: 00:26:53

Because it really explores why is someone asking for doing everything?

Dan Carlin: 00:26:58

Is it because they feel abandoned by the medical system?

Dan Carlin: 00:27:02

Is it because they're concerned that, for totally valid reasons, that the medical system would not treat them fairly?

Dan Carlin: 00:27:09

Is this fear?

Dan Carlin: 00:27:10

Is this unresolved business?

Dan Carlin: 00:27:12

It's all kind of in there.

Dan Carlin: 00:27:13

And the more we can grasp what we think is going on, the more we can actually intervene directly on it.

Dan Carlin: 00:27:19

Those are some of the big ones that we talked about in there.

Dan Carlin: 00:27:22

It really is something that we would say, do it alongside a palliative colleague.

Dan Carlin: 00:27:26

Come to us, ask us about it.

Dan Carlin: 00:27:30

Let us know what you're thinking.

Dan Carlin: 00:27:32

If you feel like there's an emotional piece going on, but you're not sure how to address it, find a palliative colleague and say, I think this is what's driving it.

Dan Carlin: 00:27:40

I really think the antibiotics aren't going to be beneficial here, but I want some guidance on how to respond to the emotion.

Dan Carlin: 00:27:47

And we're, we're really happy to help out with that.

Daisuke Furukawa: 00:27:49

I just want to say as an ID doctor who read this article many, many times, it's very, uh, yeah, this section on complex emotion is extremely insightful.

Daisuke Furukawa: 00:28:00

I especially like how there's very specific language that you can use and make those very specific examples.

Daisuke Furukawa: 00:28:08

Like I found very, very helpful.

Dan Carlin: 00:28:10

Daisuke, this is just what I do all day.

Dan Carlin: 00:28:12

This is just all day, every day.

Daisuke Furukawa: 00:28:15

I appreciate everything, all you do.

Daisuke Furukawa: 00:28:18

Thank you.

Christine Pham: 00:28:19

Before our palliative colleagues even get consulted, I see a lot of distress with, the intensivists or the hospitalists who continue antibiotics and don't have a defined parameter and they, and they want to continue it because, you know, you, the patient's family want to exhaust options

Christine Pham: 00:28:39

and they don't actually know what to measure that by, especially if, for example, there's low grade fevers intermittently from the tumor or whatnot.

Christine Pham: 00:28:47

So sometimes this is when I push for an infectious disease consult, just so maybe to give additional insight on some clinical parameters to measure as to when you should maybe consider stopping or at least some type of defined endpoint.

Christine Pham: 00:29:04

Um, also if there was a palliative consult for even maybe navigating the complex emotions of the , you know, the treating team, because it's all, for antimicrobial stewardship, it's often also navigating complex emotions of the treating providers, because they also have distress and guilt of withdrawing or discontinuing certain treatment options.

Christine Pham: 00:29:28

So, if, palliative care can also treat providers too, that would be helpful.

Christine Pham: 00:29:35

Complex emotions isn't just a course about the patient and I think the table that Dan had went into detail really helps the provider also navigate their own emotions too and how to address that with the patient.

Christine Pham: 00:29:52

It's a helpful and insightful table.

Sara Dong: 00:29:54

Yeah, I totally echo going in with colleagues and I feel like that's where I learned a lot of what language I use, is seeing other people model complex or difficult situations and being like, Oh, next time I'm going to phrase it that way.

Sara Dong: 00:30:10

Or I think we've all been in the room where like the other team comes in when you're like halfway through and asking for feedback on how you did and like how you could have done a little bit better, which can be uncomfortable.

Sara Dong: 00:30:21

But I, I do feel like many people are, are willing to do that because.

Sara Dong: 00:30:26

All of us can learn from how we talk to patients, which I think is a theme and just like you were saying in stewardship, talking to patients, really in anything even outside of end of life, but conversations about continuing antibiotics, particularly in patients that we know are transitioning to comfort care or hospice are another reason why often we're called.

Sara Dong: 00:30:48

Like maybe ID wasn't involved early on and this decision has been made and we sort of come in a little bit later.

Sara Dong: 00:30:55

And I have found that often there, you know, differing opinions and how beneficial antimicrobials are for quote symptom relief.

Sara Dong: 00:31:04

And, That is so important to inform how we explain risk benefit.

Sara Dong: 00:31:09

So I was wondering if you could talk a little bit about what we know in this space, like what's been published and any other sort of insight that you have.

Daisuke Furukawa: 00:31:17

Sure.

Daisuke Furukawa: 00:31:17

The quality of evidence about this topic isn't great, but at least from what we know, though, UTI seems to respond best to antibiotics with regards to symptom relief.

Daisuke Furukawa: 00:31:30

Depending on the study that you're looking at, the response rate, you know, might be even as high as like 90%.

Daisuke Furukawa: 00:31:35

Compare that to other infections, like, you know, pneumonia or soft tissue infections, or even like fever for bacteremia.

Daisuke Furukawa: 00:31:44

You know, the response rate probably hovers more kind of in the 20 50%, even like 0% in some cases.

Daisuke Furukawa: 00:31:50

So overall, you know, it seems reasonable to give antibiotics to treat UTIs for symptom relief, and also if the infection is clearly what's causing the symptom, like if someone has C.

Daisuke Furukawa: 00:32:02

diff diarrhea, or zoster, you know in those situations, it might be completely reasonable to just give antimicrobials try to help with the symptom management.

Daisuke Furukawa: 00:32:13

Pneumonia, I think it's probably worth talking about in itself, because it's probably what's uh, the most well studied in this kind of end of life setting.

Daisuke Furukawa: 00:32:21

The studies are a little bit mixed, but the concern with pneumonia is that, you know, there are studies that show, you know, increased survival with antibiotics, but no benefit, or even in my situation, antibiotics worsened their discomfort level.

Daisuke Furukawa: 00:32:38

So the concern is by giving antibiotics to these patients, we're just prolonging suffering.

Daisuke Furukawa: 00:32:43

And then there's also evidence to show that, you know, we can achieve good symptom control with other pharmacologic interventions as well.

Daisuke Furukawa: 00:32:50

So, one could definitely argue that you can use opiates for air hunger, or pain medications, or even antipyretics for fevers are much better interventions for symptom management than just giving antimicrobials.

Dan Carlin: 00:33:04

So this was my afternoon yesterday, was walking into the room of a patient on comfort care who had just been transitioned the night before with pneumonia, on vancomycin and piperacillin tazobactam.

Dan Carlin: 00:33:18

Being in this position again, we were, we're about to record this and I was thinking, my gosh, this is entirely relevant.

Dan Carlin: 00:33:23

And we had to tell the family, you know, it, at this point, the antibiotics are not helping him breathe better.

Dan Carlin: 00:33:30

They're not making him more comfortable.

Dan Carlin: 00:33:32

The doses he's already had will do whatever they're going to do.

Dan Carlin: 00:33:36

But continuing it is just actually extra fluid on his system that is going to result in more difficulty breathing.

Dan Carlin: 00:33:44

Because he gets more pulmonary edema, it's going to just cause the side effects.

Dan Carlin: 00:33:48

And it distracts from the focus of let's make him comfortable.

Dan Carlin: 00:33:52

Let's make sure that he has the opioids that he needs, the breathing treatments that will help him feel better.

Dan Carlin: 00:33:58

And really at this point, it isn't about the infectious process as it is about the secretions, the consolidation in the lung, all the other mechanics that are going on that are more inflammatory and don't have this infectious process going on.

Dan Carlin: 00:34:12

It was so interesting because I could tell that sometimes we have this hesitation with a family who's so emotionally vulnerable in this moment saying, yes, this treatment is no longer necessary.

Dan Carlin: 00:34:22

We're going to take this away.

Dan Carlin: 00:34:23

One of the strategies that has helped a lot is to just, as we're taking something away that is no longer indicated, try to focus on what we're giving in return and say, we know that the vancomycin is not helpful.

Dan Carlin: 00:34:37

Let's make sure that we're really aggressive in using our opioids to treat his shortness of breath.

Dan Carlin: 00:34:43

We're really helping him feel more comfortable and less anxious with other medications too.

Dan Carlin: 00:34:47

So that tends to help, I feel, with families that are really emotionally sensitive to that.

Sara Dong: 00:34:52

I'm glad you pulled out pneumonia specifically.

Sara Dong: 00:34:55

I think I was probably going to prompt and ask you about it.

Sara Dong: 00:34:58

That's perfect.

Sara Dong: 00:35:00

So, before we close out, I want to just give one more opportunity to either let you reinforce some take home points or perhaps add anything that you think we might have missed.

Dan Carlin: 00:35:10

About a year ago, uh, Daisuke and I spoke at a Grand Rounds for Infectious Diseases over at Stanford, and the best question from one of, one of the members of the audience was, in looking at all these conversations about stopping antibiotics and, and having these goals of care conversations, the question in my mind is, do I have to?

Dan Carlin: 00:35:32

And really the sense of this feels like a heavy lift.

Dan Carlin: 00:35:36

This feels like a really heavy lift to say, I am going to take on these challenging conversations and make this a part of my practice.

Dan Carlin: 00:35:43

And I really just want to stress that the point of this article wasn't to, wasn't to shame anyone or make them feel like you need to be doing this to better manage antibiotics at the end of life.

Dan Carlin: 00:35:56

So the goal of this article was actually to say, if you're feeling moral distress around this, if you feel that there could be a better way of doing it, here's some strategies to try.

Dan Carlin: 00:36:06

Some are easier to pick up, some take more practice and skill, but let's really think about the ways that we can improve our communication and meet patients and families where they are emotionally so that we're not using antibiotics to treat an emotional need.

Dan Carlin: 00:36:25

We're actually really using them for their clinical indication.

Dan Carlin: 00:36:27

That's, that's kind of the, the core piece of this is that this is meant to be tools to, to help take away the moral distress, not add to it.

Daisuke Furukawa: 00:36:35

I think that's especially relevant for like in an academic center because we might just be doing rotations.

Daisuke Furukawa: 00:36:41

We'll be on for like a week, see a patient this one time.

Daisuke Furukawa: 00:36:45

And then we'll just, we'll just sign off to the next provider, so that's probably part of the reason why we just, maybe having this conversation might feel like a heavy lift, but like what Dan said, you know, this, having these tools available, and then I think as infectious disease doctors or

Daisuke Furukawa: 00:37:00

palliative care doctors, if we collectively have all these tools, we can just, you know, enhance and better our patient care for this patient population.

Dan Carlin: 00:37:08

There's, there's one other closing thought that's been on my mind as well, and that was I have the incredible privilege to attend these debriefings with the ID fellows here, talking about the cases they find challenging, the moral distress they might feel around cases, and it's so fascinating to me because more and more as I talk to the I.

Dan Carlin: 00:37:28

D.

Dan Carlin: 00:37:28

fellows, they tell me that the reason why they came into infectious diseases is for the social histories of their patients and getting to know them and understand them and explore their hobbies, their passions, because that's part of a good history taking.

Dan Carlin: 00:37:44

What I came away with is, oh, there's this little palliative piece in these Infectious Diseases fellows that is deeply humanistic, and I walked away with such an appreciation for that.

Dan Carlin: 00:37:58

Really, there's a core of this work that has an innate bond with patients, and I think the ways that we can honor that and help that and give additional tools for that, we really want to do.

Dan Carlin: 00:38:10

So, I speak for the entirety of palliative care.

Dan Carlin: 00:38:15

When I say call on us, we really want to collaborate and if you find yourself in a hallway talking with your colleague about moral distress, then find the ways to collaborate around that.

Christine Pham: 00:38:24

Our, yeah, our palliative care colleagues have really put a lot of perspective, at least especially in the past, I want to say five years with infectious disease division.

Christine Pham: 00:38:35

I remember really clearly where, like, infectious disease physicians sometimes do just center on just infection and don't think about the entirety.

Christine Pham: 00:38:47

I think one example that palliative and ID had discussed at a case conference was basically a patient who came in with invasive, you know, mucor who had to be redlined through surgery and potentially they had not explained that half of your face will potentially be surgically removed and what that would look like.

Christine Pham: 00:39:11

It's always to be able to step back and think about functionality and after the fact and what that would mean for the patient and the collaboration with infectious disease and palliative care is actually really important.

Christine Pham: 00:39:24

It provides perspective and then it doesn't really necessarily apply to a palliative like hospice patient, but in general, we do tend to just focus on our diagnostic and in our treatment options, but not necessarily always think about.

Christine Pham: 00:39:38

The whole picture, the moral distress that we have been experiencing, like the fact that we can have tools to reach out to, is really, it mitigates that.

Christine Pham: 00:39:49

So, mitigates that distress.

Christine Pham: 00:39:51

So, that's something that I wanted to highlight.

Dan Carlin: 00:39:55

I have to give the biggest shout out to our co authors Ishminder Kaur, Emily Martin, Olivia Kates, and Tara Vijayan, who have been incredible.

Dan Carlin: 00:40:04

It has really been such a fantastic process writing this article over, gosh, like a year and a half of many meetings, a lot of bonding, just a lot of also emotional processing in the time.

Dan Carlin: 00:40:16

I'm so grateful.

Dan Carlin: 00:40:16

It was really such a collaborative work of bringing two different specialties together in multiple disciplines.

Dan Carlin: 00:40:22

And so I think we're all extremely proud of the work that we did and honestly, we could not have asked for better co authors in this situation.

Sara Dong: 00:40:29

Thank you so much to Dan, Christine, and Daisuke for joining Febrile today.

Sara Dong: 00:40:34

Super excited to have another STAR episode.

Sara Dong: 00:40:37

Don't forget to check out the website, febrilepodcast.

Sara Dong: 00:40:39

com, where you'll find the Consult Notes, which are written supplements to episodes with links to references, our library of ID merch store.

Sara Dong: 00:40:48

Febrile is produced with support from the Infectious Diseases Society of America, or IDSA.

Sara Dong: 00:40:53

Editing and mixing is provided by Bentley Brown.

Sara Dong: 00:40:57

Please reach out if you have any suggestions for future shows or want to be more involved with Febrile.

Sara Dong: 00:41:02

Thanks for listening, stay safe, and I'll see you next time.