Tuberculosis at the end of life

Dr Fiona Runacres, Palliative Care Specialist, Supportive and Palliative Care Unit, Monash Health, Melbourne, Victoria, Australia, explains the background to a longer article published in the January/February issue of the European Journal of Palliative Care.

Dr Fiona Runacres

Tuberculosis (TB) is not a common diagnosis for patients admitted to our inpatient palliative care unit in Melbourne, Australia. Which is why it came as a surprise when a patient with lung cancer, admitted for end-of-life care (EOLC), required urgent transfer back to the acute hospital based on a diagnosis of active TB from a sputum culture specimen taken six weeks earlier.

This lady was subsequently managed in a respiratory isolation room under the infectious disease unit in the tertiary hospital, which was quite a contrast to the hospice environment she and her family had become accustomed to. She was not considered well enough to benefit from TB treatment and died two weeks later in the acute setting.

Another patient with a recent history of lung cancer and active TB was subsequently referred to our unit during the same month. These admissions lead us to consider how we, as an inpatient and consultative specialist palliative care service, can manage the EOLC needs of these patients. Furthermore, how can community palliative care services best manage patients with potential or confirmed TB who wish to die at home? Questions were raised as to how other patients, staff and family members could be protected from possible TB exposure in the future.

A review of the literature found most evidence relates to palliative care needs for patients with drug-resistant TB, and is set in countries with a high prevalence of TB. Little is available to guide screening and management by palliative care services for patients in countries such as Australia or the UK, or to guide EOLC provision in hospices or community settings.

Our paper published in the January/February issue of the European Journal of Palliative Care raises several issues for palliative care clinicians and services, e.g. deciding who to screen and how; and managing the risk of infectivity for family and staff members while awaiting results of screening or diagnostic tests. Diagnosis of active TB is not straightforward either, as available screening tests lack sensitivity and specificity,1 and definitive tissue culture tests may take longer to return results (up to six weeks) than some patient prognoses. For patients with TB and other advanced illnesses, such as lung cancer or chronic obstructive pulmonary disease, deciding upon active treatment of their TB is difficult. There may be a benefit for symptom management or to minimise transmission, however balancing treatment with an otherwise palliative approach poses challenges for palliative care clinicians.

In summary, more consideration is needed in the best management of palliative care patients with possible or drug-sensitive TB; determining the care required in various palliative care settings; and the protection of families, staff and communities from a public health perspective.

Links

Reference

1. Dinnes J, Deeks J, Kunst H, Gibson A, Cummins E, Waugh N, et al. A systematic review of rapid diagnostic tests for the detection of tuberculosis infection. Health Technol Assess 2007 Jan; 11 (3) 1-196.

Read the full article in the European Journal of Palliative Care
This post relates to a longer article, ‘Tuberculosis at the end of life’ by Runacres F, William L, Ingram A, Franco M, Yoong J and Poon P, published in the January/February 2017 edition of the European Journal of Palliative Care (vol. 24.1). 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 – just choose the year ‘2017’. 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.

Look out for more on tuberculosis and palliative care in the future . . .

Read more posts relating to articles published in the European Journal of Palliative Care on the EAPC Blog

 

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