Antibiotics for URI when on Hospice

  1. How do you all feel about antibiotics for URI? All of my case load is in either Long Term Care facilities or Alz Units. I am questioning the need for antibiotics for these patients. Is the antibiotic for comfort (as it would be for a symptomatic UTI)? The patients may certainly die from the URI & they do have uncomfortable symptoms. How do we rate the need for antibiotic use? Sometimes it feels like the family & CG's are really wanting to extend the patients life. So are these patients really hospice appropriate?

    Thanks for your feedback,
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    About Sharry RN

    Joined: Feb '09; Posts: 17; Likes: 12
    Hospice Case Manager
    Specialty: 24 year(s) of experience in Hospice, Psyc, post surg


  3. by   kelluvanurse
    If your loved one had a terminal illness such as the late stages of alzheimers would you want them to die from the illness itself or from the uti that they developed which could have been prevented if treated. Hospice should not take measures to stop progression of the terminal illness but anyone can develop a uti. Hospice is not there to speed up the process by not taking care of other things that come up. If they develop a temp, arent you going to give them tylenol. When I worked at the hospital and I had a pt who was a dnr and something would come up I would get so mad when I called the physician for something and he would say"why are you callling me, they are a dnr!". Hello, they may be dying but lets let them die from the terminal illness itself instead of something else, that is just pure neglect.
  4. by   leslie :-D
    yes, yes, YES, you treat infection w/abx.
    hospice is for terminal folks in LIVING out their remaining time with as much quality and comfort as possible.
    infections hurt, and need to be treated (as long as it's not r/t adm dx).
    we are not there to kill them, but to let them die.
    big difference.

    definite sore spot of mine.
    yes, to abx.

  5. by   caliotter3
    I see it as a comfort measure and support the practice for this reason.
  6. by   KateRN1
    Do Not Resuscitate does not mean Do Not Treat.
  7. by   maplern
    I agree with all of the above. This is an advocacy issue. Infections = s/s of discomfort. We treat to provide comfort.
  8. by   Spidey's mom
    An upper respiratory infection (URI) may be problematic depending on the terminal illness and the stage of dying.

    We've had quite a few lung cancer patients recently - end stage. I don't think we would have treated an upper respiratory infection. However we did take a Dilantin level on one of these patients and up his meds due to increased seizure activity.

    As to a urinary tract infection that another poster mentioned - we've treated those. One patient was on prophylactic antibiotics because she was bed bound and at risk for developing decubs.

    I agree that DNR does not mean Do Not Treat.

  9. by   Sharry RN
    Thank you to all who replied. I appreciated your input.

    It really makes a difference if you know the whole story & that story varies from patient to patient, family to family. Just in the last 2 weeks, I had a family decide not to treat an aspiration pneumonia because there was no way to keep the patient from aspirating, he even aspirated on his own saliva. Another family chose not to tx an URI, but the MD chose to ignore their request & treated a non-exisistant UTI with Levaquin. Another family was told by the patients MD that pneumonia "Was the old-man's best friend". The other family I had made mention of took my advise not to treat a low-grade temp & cough with an antibiotic & the following Monday the patient was fine (no cough or temp).

    All "in the life of a Hospice Nurse". On a personal note, I'm off for the next 5 weeks for a much needed vacation.

    Thanks Again for your input.
  10. by   Ginapixi
    I always ask myself "what would I want if I was the patient"; I do not think I would my URI treated with antibiotics, just keep me comfortable; a UTI on the other hand might be quite painful and I think I would want it treated, or at least the pain/discomfort treated - on the other hand my living will states NO ANTIBIOTICS!
    we have a quite a few patients, they get started on antibiotics for a few days then die any way before the course is ever finished, so if they were more comfortable great; on the other side of the coin: we waste a horrendous amount of meds (money); it is a decission pts/families need to make, not mine.
  11. by   rnboysmom
    WooHoo, what a touchy topic. Responses are interesting here, even in this column. Interesting response by leslie "infections hurt and need to be treated(as long as it's not related to the adm. diagnosis)". Hmmm, I have seen too many of Leslie's responses to believe that she means "we can treat them if they hurt for something that's not related to the terminal diagnosis, but not if it is related to the terminal diagnosis". Leslie's responses are too humane for that type of intended response. We all have personal opinions here, so here goes mine:

    We treat symptoms and promote comfort. Hospice is a philosophy of care, and that philosophy is different to different cultures, families and individuals. We really do "have to listen and know our patients", asShariWN admirably states. This is not about our opinions, but rather, about the patient and the family unit. How often does an AIDS patient actually die from the disease itself????(very rarely--death is usually from an opportunistic infection) If we treat every single opportunistic infection that pops up during the course of the hospice AIDS patient, we are, in all likelihood, going to cause suffering to that patient, and to that family unit. Our jobs as hospice professionals is to listen, to guide (when asked)and to promote comfort always. Many disease courses, Alzheimer's, Failure to Thrive, have a very, very low mortality rate of themselves. The "killers" in FTT or Alzheimer's patients are the pneumonias, UTI's and aspiration events. How long do we continue to treat these? Always, per request, sometimes per guidance, and rarely if we are at a point where the family is on board, the patient is ready and if the infection is causing no discomfort.
    If the patient and family have accepted the philosophy of care----we treat the symptoms and provide the comfort and the tools to say goodbye. Recently read a large study with geriatric population and mis-use, abuse of antibiotics for common infections URI's,UTI's----arrrrgggghhhhh, can't find the reference for this column, but the results were favorable towards not treating every infection in the elderly. Along with treating infections comes the risk of C-Dif, fungal and yeast infections and thrush (all of which can be more uncomfortable than the original infection) along with unintended potential side effects, diarrhea, decreased appetite, confusion, psychosis and the set-up for super-infections if we are not able to get every single dose down the patient .Several studies show "less is best" when it comes to adding medications to the elderly patient's regime. Absolutely, DNR does not mean Do Not Treat--- but personal preference is treating the symptoms and allowing nature to take it's course if the patient and family have accepted the philosophy. Very, very frequently, the current pneumonia or UTI (that could lead to sepsis and death) is a much, much more humane death than what is around the corner for patients of certain diseases (metastatic bone cancer, COPD, SC lung, ALS, etc).
    Okay, that's my personal opinion, now, have at it.....
    Last edit by rnboysmom on May 13, '09
  12. by   KateRN1
    Thanks for pointing out the possible side effects of abx treatment. The alteration of the normal gut flora is a serious issue in all pts receiving abx and should be discussed when making a decision regarding abx tx.
  13. by   Higgs
    Hospice does not mean stop all treatment. It means no CPR or ICU. Its goal is peaceful, natural death. For someone to live a full life, develop cancer/Alzheimers or whatever but then to die of a chest infection (fever/secretions/shortness of breath and the sepsis that goes with it) that could have been treated is a disservice to the patient and their families.

    However, we always talk things through with familes and patients - let them know what the full picture is, and come up with a plan that everyone agrees with. Some familes want no antibiotics. Some familes want everything the physician can throw at the patient right up until the end. We even had a family of a terminal patient say that perhaps their relative would have lived a little longer if they had been on an IVI - even after many, many conversations over the pros and cons of fluids in end stage disease.

    It's never the same twice. Dont forget that in Hospice care, we're kind of treating the family too. What we dont want is a patient's death and the family start saying 'our relative died too soon because you didn't treat XXXX like we asked.' (It does happen...)

    If we routinely stop treating bad chests in hospice because they are going to die soon anyway, then why bother with analgesia and any other meds?

    Just my view...
    Last edit by Higgs on May 24, '09 : Reason: TYPO
  14. by   hickjoe
    I am the widow of a patient who died almost a year ago while in hospice at home. When my husband got his first URI we left it up to him as to whether or not he got antibiotics - even though he did have a DNR. He chose to fight the infection and I was with him 100% as were the hospice professionals. When he got the second infection he was more ready for the end to come and decided not to treat the infection which spread to his entire body and finally killed him. It was not a pretty thing to watch and I wish I could remove those pictures from my mind. But in the end I believe it was his decision to make even though I would have wanted him to stay here with me.
    Given where you work and the type of patient with whom you work, your situation is very different and much more complicated. If a patient did not develop a living will or health care directives before he/she became mentally incapacitated, my guess is you would have to turn to the family and the physician for guidance. I feel that the quality of one's life is an important guidepost. But I do not have any hard and fast rule to go by. My husband and I had discussed in great detail how he wanted to live and how he wanted to die so for us it was not an issue. I applaud your professional decision to work in the area you do. Bless you!