Dr Eng Koon, Division of Palliative Medicine, National Cancer Centre Singapore, explains the background to his longer article, published in the current edition of the European Journal of Palliative Care – a reminder that even common (and seemingly uncomplicated) treatments need to be carefully considered in palliative care.
Imagine yourself having the flu. You speak to your colleagues and all of them swear by having antibiotics as essential. Instinctively, (and with less than subtle probing by your anxious spouse), you ask your doctor for antibiotics although he says it is likely that it’s a viral infection. You recover within a week (albeit with some loose stools), and obviously you are glad that you asked for antibiotics in the first place.
Now imagine instead that you developed massive diarrhoea from your antibiotics requiring hospital admission and parenteral hydration. As you are discharged three days later you comfort yourself that the antibiotics may have aided your recovery from flu. But as you are walking out of the hospital your doctor tells you:
“You know, I wouldn’t recommend you take the same antibiotics again as they caused such a bad side effect. And to be honest, I think your flu might have resolved earlier if you hadn’t been so dehydrated.”
As your heart sinks, along with a part of your self-esteem, try to answer this question: “Would you want to take antibiotics for yourself (or your family) if someone develops flu again?”
It is common for patients and caregivers to struggle to understand exactly what medical intervention is being offered. For example, to ‘simplify’ matters, Cardiopulmonary Resuscitation (CPR) is commonly prescribed simply to facilitate chest compressions or endotracheal intubation – a tube in the windpipe to help one breathe. In contrast, the option of giving antibiotics is something I find relatively easy to offer and which is then usually accepted. I can almost imagine patients and family members having a thought bubble immediately after they hear the word ‘antibiotic’, containing phrases like “Ah yes, for infection,” and “Of course I would take it and kill the darn bacteria.”
As you attempt to answer the question above, imagine that now you are a hospice patient with a prognosis of less than three months. Your swallowing function is deteriorating and you will likely require intravenous antibiotics the next time you develop a fever. Your veins are burnt out from chemotherapy and you hate venepuncture. Would your answer differ?
The offer of antibiotics for hospice patients is thus not as straightforward as it seems, especially when the evidence supporting antibiotic use for hospice patients remains elusive with regards to mortality benefits, and at best weak for symptom alleviation. At the end of the day, clinical practice will have to be guided by the goals of care of the patient, balanced by the burdens of treatment.
Physicians should continue to be cognizant of their prescribing patterns and recognize the limitations of this powerful tool that was first presented to us more than 50 years ago.
Read the full article in the European Journal of Palliative Care
This post relates to a longer article, Use of antibiotics in Singapore by Ong Eng Koon and Chong Poh Heng, published in the November/December 2016 edition of the European Journal of Palliative Care (vol. 23.6).
If you have a web-based subscription to the journal you’ll be able to download this issue, plus all articles in the journal archive. You can also browse the archive and download articles by taking a 10-minute or 30-minute subscription. Members of the EAPC receive discounted subscription rates to the journal – click here to subscribe online.
Read more posts relating to articles published in the European Journal of Palliative Care on the EAPC Blog.
EJPC Palliative Care Development Award 2017 – nominations form now online.
Do you know someone who has made a major contribution to palliative care policy development? Why not nominate them for the EJPC Palliative Care Policy Development Award? Click here to nominate. Launched by the European Journal of Palliative Care in collaboration with the European Association for Palliative Care, the award is aimed at professionals working in palliative care worldwide who have made a substantial contribution to policy development through research, clinical practice or as policy activists.
The 2017 Award will be presented at the 15th World Congress of the EAPC in Madrid, Spain (18–20 May 2017). Deadline for applications: 31 March 2017.