GPRs for use of antibiotics towards the end of life
These recommendations apply to adults approaching the end of life. Anticipatory care discussions with patient and families should ideally take place long before this point is reached.
1. Involve patients in shared decision making about future care
The evidence suggests this is the most important aspect of care for patients and their families and carers.
a. Decisions about antibiotic prescribing towards the end of life should be taken jointly between the clinician, or in some settings the multi-disciplinary team, through discussion with the patient and, where appropriate, their family or carer. This shared decision-making process not only involves informing the patient of the potential benefits and risks of antibiotics but also taking the time to understand the patient’s immediate priorities. For further information refer to Shared decision making | NICE guidelines.
b. Discuss current and future antibiotic prescribing decisions as part of anticipatory care planning conversations, document in the clinical notes and include in the patient’s Key Information Summary. This discussion should include route of antibiotic therapy as intravenous treatment would usually necessitate hospital admission.
c. Where patients lack capacity, guidance from Scottish Government on Adults with incapacity should be followed. Consider the patient’s pre-existing wishes in the context of the clinical situation. The benefits and risks of antibiotic therapy should be discussed with any proxy decision maker or family acting in the patient’s best interests.
2. Agree clear goals and limits of therapy
These should be defined and agreed with the patient/family/carer after considering the following:
a. The principal purpose of antibiotics at the end of life may be to relieve symptoms or may potentially be to cure infection.
b. An infection should not necessarily be treated simply because it is treatable. Likewise, a positive microbiology result should not lead to an antibiotic prescription if there are no significant symptoms.
c. Consider whether hospital admission if required for IV antibiotics is in keeping with the patient’s preferred place of care towards end of life.
d. There are risks associated with giving antibiotics (including side effects, difficile and antimicrobial resistance).
e. Infection may be reversible and clinicians want to offer treatment. However, this should be balanced against potential antibiotic-related toxicity.
f. If an antibiotic is prescribed, follow local guidance on drug choice, dose and duration and ensure a stop date is recorded.
g. Overall benefit for each individual patient should be the goal of any treatment as per General Medical Council guidance on Treatment and care towards the end of life
h. Seek advice from palliative care specialists if required.
i. Delirium is very common and often attributed wrongly to infection. It is important to consider other contributing factors (including that the person may be dying and terminally agitated)
3. Consider alternatives to antibiotics in adults approaching end of life
a. Scottish Palliative Care Guidelines have advice on other medicines including mucolytics, muscle relaxants, analgesics, anti-pyretics and antitussives that can be used as alternatives to antibiotics for relief of infection-related symptoms.
b. Oxygen and non-pharmacological methods such as a handheld fan may be helpful for dyspnoea.
4. Review all antibiotic prescribing decisions regularly
a. Review and discuss antibiotic prescribing immediately in an acute severe infection where it emerges that the patient is at the end of life.
b. If an antibiotic is not helping or is causing side effects, the discontinuation of treatment should be discussed with the patient, carer and family where appropriate.
c. If the person being treated wishes to stop an antibiotic at any time, this decision should be respected and treatment should be discontinued.
d. Antibiotic therapy should not routinely be escalated in the deteriorating patient at the end of life (this includes use of broad spectrum or intravenous antibiotics).
Scottish Antimicrobial Prescribing Group (SAPG) | October 2023 for review October 2026
Content updated: January 2024