Withdrawing antibiotics in the terminally ill ICU patient: Should it be a road less travelled?

“First I will define what I conceive medicine to be. In general terms, it is to do away with the suffering of the sick, to lessen the violence of their diseases, and to refuse to treat those who are overmastered by their disease, realizing that in such cases medicine is powerless.” Hippocrates, c460-370 BCE

Palliative care incorporates holistic care and a multidisciplinary approach to support patients and families facing terminal illnesses. While recognizing that the treatment of infections can suffice in good palliation, the indiscriminate use of broad-spectrum antibiotics cannot be ignored in clinical practice. Healthcare professionals are driven to life-saving and sustaining care (“rule of rescue”) in the intensive care unit (ICU), with the prognostication of death not part of care goals. Withdrawing antibiotics can be emotionally daunting even to the most experienced intensiveness, resulting in a lack of conviction in the decision to stop treatment in the terminally ill patient.

Individual justice in society is essential, and the patient has a right to healthcare treatment. However, the focus should also be on the public (communitarianism) while still protecting vulnerable ICU patients who lack decision-making capacity. Broad-spectrum antibiotics can have severe side effects and result in the emergence of multi-drug resistant (MDR) pathogens that impact the outcome of other patients in the unit and community. ¹ In fact, it has been estimated that 10 million people will die every year due to antimicrobial-resistant organisms by 2050. ² Therefore, we have a moral obligation to preserve antibiotic sensitivity with appropriate stewardship in the ICU for future generations to come. ³ Distributive justice dictates a scenario of limited resources in the ICU, which includes pharmaceutical products. ⁴ Treating MDR pathogens requires prudent use of restricted antimicrobials with solid regulatory systems when utilizing antibiotics in short supply. The prioritarian might allocate scarce resources, such as limited antibiotics, to individuals with a good prognosis for recovery rather than the terminally ill, while the egalitarian will support antibiotic stewardship to ensure equal opportunity for all to a restricted antibiotic. ⁴

Integrating clear documentation and palliation policies, together with ethical and multidisciplinary team consideration, can act as a facilitator to decrease the use of limited resources and antibiotics in the end-of-life ICU patient. ⁵ An integral part of the care model is to approach family members with compassion, non-judgmental, and honest communication when discussing the withdrawal of antibiotics. The aim should not be to prolong life but to maintain dignity during death, improve the quality of life, and support family members during the bereavement period. The answer to the question of when to let go and stop antibiotics cannot be defined in a textbook or journal article; these answers are only found at the patient’s bedside.