Rethinking Antimicrobials in End-of-Life Care: Navigating Evidence, Ethics, and Practices

Key Message: Antimicrobial use near the end of life (EOL) is common, often continued with assumed minimal harm and for symptom management. Yet, evidence is limited, and guidelines are lacking. Treating antimicrobials as a low-priority topic in goals-of-care discussions overlooks harms and conflicts with patient-centered values, underscoring the need for clearer guidance.

Abstract:

Introduction: At EOL, antimicrobials are frequently continued without a clear indication of palliative benefit (1-3). Antimicrobial management is often omitted from goals of care conversations, as clinicians may prioritize decisions about resuscitation or life support and worry about overburdening patients and families facing complex EOL decisions (4-5). This omission is further complicated by a lack of formal guidance from palliative care and infectious disease specialties on best practices in this context (1).

Objectives: To provide expert-level guidance on antimicrobial stewardship at EOL.

Methods: Through quantitative research, literature synthesis, and expert consensus, an interprofessional and interdisciplinary panel will 1) present the prevalence and reasons for antimicrobial use among terminally ill patients across settings (hospital, community), 2) describe burdens or benefits of antimicrobial use at EOL, 3) examine the role of palliative care clinicians in alleviating infection-related distress and facilitating shared decision making around antimicrobial choices, 4) outline barriers to antimicrobial stewardship at EOL, including challenges faced by primary teams, 5) clarify ethical and cultural influences in withholding, withdrawing, or continuing antimicrobials at EOL, and 6) identify strategies to address the current lack of infectious disease and palliative care guidelines on EOL antimicrobial use. Concepts will be presented through case vignettes, highlighting the unique expertise of interprofessional palliative team members and the value of collaboration with infectious disease and primary teams.

Results: This panel offers concrete recommendations for interdisciplinary teams at generalist and specialist levels to support antimicrobial stewardship at EOL, emphasizing the ethical dimensions and implications for shared decision-making. A moderated discussion will equip attendees with evidence-based strategies to inform clinical frameworks, research, and policy development.

Conclusion: Clinical decision support on antimicrobial use at the EOL is limited. Through cross-team collaboration, it is possible to optimize antimicrobial stewardship while meeting the needs of patients and families at the EOL.

References: 1. Rosa, W.E., Pandey, S., Wisniewski, R., Blinderman, C.D., Cheong, M.W.L., Correa-Morales, J.E., Cubides-Diaz, D.A., Folorunso, S., Gafer, N., Marhoom, M.K.A., Newman, T., Ntizimira, C., Obadare, T.O., Papan, C., Perez-Cruz, P., Radbruch, L., Rajahram, G.S., Reyes-Barros, T.A., Salins, N., Saravu, K., Sullivan, D.R., & Dee. E.C. (2025). Antimicrobials in serious illness and end-of-life care: Lifting the veil of silence. The Lancet Infectious Diseases, S1473-3099(24)00832-6. Advance online publication. https://doi.org/10.1016/S1473-3099(24)00832-6
2. Pandey S, Wisniewski R, Morjaria S, et al. Factors associated with antimicrobial use at the end-of-life among hospitalized cancer patients. Am J Hosp Palliat Care. 2024;41(1):8-15. doi:10.1177/10499091231160185
3. Karlin D, Pham C, Furukawa D, et al. State-of-the-Art Review: Use of Antimicrobials at the End of Life. Clin Infect Dis. 2024;78(3):e27-e36. doi:10.1093/cid/ciad735
4. Larnard J, Stead W, Branch-Elliman W. Considering Patient, Family, and Provider Goals and Expectations in a Rapidly Changing Clinical Context: A Framework for Antimicrobial Stewardship at the End of Life. Infect Dis Clin North Am. 2023;37(1):139-151. doi:10.1016/j.idc.2022.09.003