This StAR episode features the CID State-of-the-Art Review on use of antimicrobials at the end of life.

Our guest stars this episode are:

Daniel Karlin (University of California Los Angeles, UCLA)

Christine Pham (UCLA)

Daisuke Furukawa (Stanford)

Journal article link: 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

Journal companion article - Executive summary link: https://academic.oup.com/cid/article/78/3/493/7596075

From Clinical Infectious Diseases

Episodes | Consult Notes | Subscribe | Twitter | Merch | febrilepodcast@gmail.com

Febrile is produced with support from the Infectious Diseases Society of America (IDSA)

Hi everyone, welcome to Febrile, a cultured podcast about all things infectious disease.

We use consult questions to dive into ID clinical reasoning, diagnostics, and antimicrobial management.

I'm Sara Dong, your host and a MedPeds ID doc.

I am excited to be joined by three guests today.

First up, I have Dr.

Christine Pham.

Christine is one of the Antimicrobial Stewardship and ID Pharmacy Leads at UCLA.

She is continuously engaged in University of California wide antimicrobial stewardship and educational outreach initiatives.

She also served as the 2021 2022 lead of the UC System wide ASP Collaborative.

Hi, this is Christine.

I'm excited to be here and sit with you guys to talk about our topic today.

Next, I have Dr.

Daisuke Furukawa.

Daisuke is a clinical assistant professor in the Division of Infectious Diseases at Stanford University.

He has a passion for antimicrobial stewardship, and his current clinical and research focuses are primarily in orthopedic infectious diseases.

Hi, I'm Daisuke.

Thanks for having me.

Excited to be here.

Dr.

Daniel, or Dan Carlin, is a Los Angeles native trained in internal medicine, pediatrics, and palliative care.

He's an assistant clinical professor in palliative care at UCLA.

He's passionate about all things communication related and wishes he could better remember all those antibiotic regimens from residency.

Hey there, I'm Dan Carlin.

It's really great to be here.

Thank you for having us.

As everyone's favorite cultured podcast, we like to ask if you'd be willing to share a little piece of culture, basically just something non medical that you have enjoyed recently or that brings you happiness.

I'll start with you, Daisuke.

I have a almost three year old son, so he is obviously my greatest joy.

Even through the highs and lows of the terrible twos, it brings me great joy.

What about you, Christine?

So recently, I enjoyed, I mean, there's downstream effects of having, when you read Reddit threads, but I was helping my sister negotiate the price of a new car down.

And we actually were looking at subreddit threads that were really helpful and informative to know what customers got out the door.

for different cars in different states so that we felt good about the price that we were able to negotiate down to.

So that was something that was a recent experience and I haven't really appreciated Reddit really fully until that was what I enjoyed most recently.

Yeah, Reddit is definitely its own culture and world.

It is.

It is.

Awesome.

And what about you, Dan?

I also have two young kids, so our house is constantly awash in Bluey, which is amazing and I highly recommend it to everyone.

The one thing I've been reading is a book called How to Be Perfect, The Correct Answer to Every Moral Question by Michael Schur.

He's the guy that wrote The Good Place and was involved in The Office, and it's just this dive into ethics, but told through a very comedic lens and extremely relatable.

So I highly, highly recommend it.

Sounds good.

I'm going to have to add that to my list.

Well, thank you guys for being here.

You know, we're welcoming everyone to another STAR episode, which is focused on these State of the Art Reviews from the CID Journal.

And you and your colleagues have created an article that's wonderful about thinking and approaching the use of antimicrobials at the end of life.

And so we are going to chat about some clinical scenarios in the episode, but I actually like to start by just opening the floor to ask if you might give an introduction to the topic, goals you had for the article or other major considerations you had as you set out to make a review like this.

Yeah, absolutely.

To give a little context to this, rewind all the way back to pre pandemic 2018, 2017, I think, where, in the hallways of Santa Monica Hospital, where I was a palliative care physician, Daisuke was a fellow at the time in ID.

This came out of conversations with all of us together, including Dr.

Tara Vijayan, our fantastic ID colleague, just about the moral distress that we felt around a lot of patients that we were taking care of, where it felt like inappropriate or non beneficial antibiotic use in the context of someone with a really poor prognosis or where we weren't talking about goals of care.

And those initial hallway moments of airing our moral distress actually led into just these ongoing conversations about how do we bring the palliative lens into infectious disease and really try to have some strategies to deal with what we're seeing on a regular basis to better approach this.

And so that's actually where it came out of, and it just evolved and evolved over time into greater collaboration between our groups, and then ultimately this article.

Yeah, that's awesome.

And today, along with a lot of Febrile episodes, we're going to use the scenario of a patient to talk through what you have, at least, started to talk about in the article and that many of us experience when we're on consult service.

And so a scenario of a patient with a malignant obstruction that leads to recurrent abscesses.

And so I'll give us a little intro to our patient.

She is a 67 year old woman with newly diagnosed unresectable cholangiocarcinoma who begins chemotherapy.

She subsequently develops fever, loss of appetite and right upper quadrant abdominal pain resulting in hospital admission.

On admission, she started on piperacillin tazobactam, and a CT scan reveals several rim enhancing fluid collections in her liver.

A percutaneous biliary drain is placed, and fluid from this procedure grows at Enterobacter cloacae complex.

Her oncology team is preparing to discharge her home.

We often get called in dilemmas like this, uh, such as when source control might not be really feasible, how might we, as the ID team, help with conversations about discussing the infection and treatment plan in something like this situation?

ID doctors can really help with setting expectations about not only the the treatment plan, but also in terms of the long-term outcomes and natural history of an infection like this, so this is clearly a source control issue.

Infection eradication is extremely challenging, if not impossible, and there's a very high likelihood of infection recurrence or persistence.

What ends up happening is we go through this downward spiral of giving antibiotics, infection comes back, oftentimes with a much more resistant organism, so we have to resort to broader spectrum antibiotics.

But the infection still comes back, and then we just kind of go through this cycle of infection, antibiotics, infection, antibiotics.

As ID doctors, I think we really have a good understanding of this process very well, so we can help patients understand the limitations of antibiotics, but also to help them understand that infection, in this case, is more of a like a symptom of the underlying disease.

In this case, cancer, rather than it being like an independent disease process.

So I think as an ID doctor, we can really help patients understand the infection in the context of the greater underlying disease process.

I think that's really important.

A couple of other things that I want to point out is that I think conversations like this, we should do it early.

So you know, don't wait until the fourth, fifth, sixth admission the patient experiences.

You can start having these conversations very early on.

And I think that's just better for the patient, and it'll also help us build better trust and better relationship with the patient as well.

And then lastly, I think another important point is also to have a similar conversation with other providers as well.

So in this case, it'll be like the oncologist, or even the surgeons, or the other proceduralists, even the outpatient primary care doctor.

So that we can just kind of all be in the same page and deliver the same message to the patient.

And going off that, Daisuke, I think there's like this really key piece of what do we define as incurable?

What do we define as a process that is just not going to go away on its own and we will constantly be dealing with it?

And I think It's rare that we actually give that name to an infectious process where we can explain it in a way that a patient's going to understand.

This is going to be for the remainder of their life, something that will drastically change their trajectory.

And having that be clear, having that be extremely explicit is really important.

Well, I think in this patient case, when you have something that's unresectable, when you have lack of source control, that's where the communication needs to be transparent to the patient and to the providers that there's going to be a high probability of recurrence.

I mean, it's going to be hard to pivot and tell the patient that at some point this is going to potentially be incurable, but there is going to be a high risk and high likelihood of that.

And when the providers are comfortable doing these early conversations, it's going to be challenging.

Usually with the first episode, and maybe even the second episode, everyone's usually optimistic as to whether we even should broach that subject, but it becomes clear when they have a poorer and poorer prognosis or they're becoming readmitted.

To define that point is actually really challenging for all providers.

Infectious disease physicians would be a good point of access or contact to actually be able to make that more transparent for everybody.

And just like you said about talking to the whole team and making sure that everyone is communicating that same message.

I think in the beginning, that's when it is really challenging.

That sometimes the patients receive information of a huge spectrum of where this infection will ultimately end up.

Well, this patient in this scenario is discharged home with cefepime, but develops distressing anasarca.

She follows up at a visit with her ID physician and a switch to oral trimethoprim sulfamethoxazole, but develops severe nausea and vomiting, leading to readmission for dehydration.

During this hospitalization, her biliary drain is replaced.

There are two additional drains inserted.

The cultures from these drains are growing now drug resistant E.

coli.

Due to resistance and intolerance, the ID team identifies no appropriate oral antibiotic options.

So this time, she's discharged with ertapenem with a plan for a close follow up in clinic.

Over the next several months, antibiotics are stopped intermittently due to ongoing side effects.

You know, she continues to have these hospitalizations that we talked about, uh, with recurrent abscesses and consultants from GI, IR, and general surgery are agreeing that definitive source control is not possible.

So we started to talk about this conversation a little bit, but how do we address antibiotic use in a context like this?

So I'll explain.

Span a little bit more as to why we wanted to focus on the patient doing rounds and rounds of different antimicrobials.

It's based on the assumption that a lot of patients and a lot of providers think that antimicrobials are a low risk intervention, but in reality, all antimicrobials have some side effects, may have a downstream effect, and this patient had trialed bactrim, cefepime, and ertapenem, which were becoming

more broad spectrum antimicrobials, and then we're approaching to a point where we're no longer curing it and just trying to control the infection.

That needs to be communicated that we're reaching to a point where there's going to be less benign drugs and it's going to be contingent on whether the patient is tolerating it and whether there will be emerging drug resistance.

That also needs to be communicated to the patient, patient's family, and also to the providers that antimicrobials are not something that can be considered as a low risk that you can potentially give for an indefinite amount of time or undefined duration.

And that's why this feels like a transition point, honestly, is that whenever we're getting to a point that someone is going on long term IV antibiotics, where there's suppressive antibiotics coming in, they've failed multiple lines, we're getting to a point of resistance, this is where we actually really need to define that we're in a different place.

And in the same way that the oncologist would say, well, we're switching from curative treatment to palliative treatment.

It's time to talk about goals of care.

I think that's what's coming up in this as well, is that we actually need to use this as a hallmark of, all right, let's talk about where this goes if we keep going down this road.

And that's kind of why we wanted to introduce the, the palliative lens and the structure of how to have these conversations around goals of care from an earlier perspective and exploring what a person's goals around this infection might be.

Now, in our heads, we always play out this conversation of like, they're going to ask me to just treat the infection, right?

That is going to feel like the only goal that they're going to give me.

We really want to open it up in terms of larger range of values that might be important to them and especially what their worries are about the future.

What we brought in and what we talked about in the article is this framework called the REMAP that comes from Vital Talk, which is this really large organization that does a lot of great work in communication and palliative care and oncology about how to structure this conversation.

And REMAP stands for reframe, expect emotion, map out patient goals, align with those goals and propose a plan.

In this kind of context, it really goes into kind of breaking a little bit of bad news.

Hey, let's reframe the situation that we're in.

We've been able to control this only with oral antibiotics so far.

We're in a different place right now.

We're going to have a harder and harder time controlling where this goes, that might be met with emotion that might not be.

We'll talk a little bit more later about how to respond to those emotions if we need to.

But really helping break the news that this is getting more incurable and that this might actually be a life limiting illness independent of the cancer itself.

Um, and if that can be communicated, that might actually bring up a lot of emotion for someone.

You know, we then map out values, meaning, what's important to you?

What do you want to prioritize when we think about treating this infection?

Is it only going to be about using the strongest medicine regardless if you're on an IV course for six weeks at a time?

Is this going to be more about, are there any side effects that are intolerable to you?

What do you want to really focus on and make sure that we're being mindful of as we think of your treatment?

We align with those and really show that we respect those values, that they're informing the choices that we make as physicians, and then we propose a plan.

And that might be something where we say, you know, planning out the future, we might need to talk about a point where these procedures and antibiotics are not actually helping you live the quality of life that you want to have.

We need to think about what do we do when we reach that point, and it's not benefiting you as much.

That's kind of what we want to sketch out.

And in the article, it goes into a bit more depth and tries to provide some phrasing around it.

But really, it's about taking the structure that we know works in a palliative kind of context and saying, when infectious processes become incurable and become life limiting, how can we start to have goals of care discussions around that?

This patient becomes confused and drowsy at home, is again readmitted for AKI and fluid refractory hypotension.

She is transferred to the ICU for pressor support and management of septic shock.

In this setting, the ICU team has started meropenem and vancomycin empirically.

Blood cultures now grow Candida species and the ID team recommends adding caspofungin.

Per the oncology team, her chemotherapy is on hold until the candidemia is appropriately treated.

Really, they're thinking that it's unlikely to be continued due to her overall physical deconditioning and comorbidities.

The palliative care is involved and the patient agrees to transition to home with hospice care if the patient is stable for discharge.

They request to continue the same antibiotics while on hospice.

Understanding the benefits of antimicrobial therapy at the end of life is so challenging.

And I think people have very different expectations.

I was wondering if we could talk about that a little bit, you know, how do we navigate this in a patient centered way where we are aligning with what they'd hope for, but trying to provide the best advice about how truly useful antibiotics are at this point.

Really, we're talking about a situation that I, and again, speaking as a palliative doc with a lot of fantastic ID colleagues, many, many, many ID physicians are facing this.

When antibiotics are started in a late stage ICU situation, they're sort of bundled with an entire septic shock presentation.

And we know that it's probably not going to change the trajectory of their course.

It's going to get added on and probably not taken off in a reasonable time frame when the infection isn't really driving the picture anymore.

But it's just going to be sort of part of the scenery, meaning like we, we just have to have it on and it's got to stay on and it's, we're going to breed some resistance out of that.

And that's really challenging.

And we want to, we want to find ways that antibiotics are in the service of larger goals, not that they're just started and continued indefinitely and the ways that we can think of antibiotics and explain this to patients and their families in a bit of a different way can really change the way that we are using them.

You know, REMAP still really applies here where if we need to have larger discussions about an end of life infectious process, we can really propose that and we, we provide language that's a bit different for this timeframe, about how we're concerned that we might be getting closer to the end of life, and how we might need to explore what their values are.

One of the key questions that comes up all the time is when we have patients on IV antibiotics that are started, let's say, for a pneumonia or sepsis, the person stabilizes, that patient is not able to take anything oral.

And families ask to continue IV antibiotics at home while on hospice.

We know that that's probably not going to change their overall course of their level of comfort.

It's not going to really improve their sense of well being while at home.

They're probably not even going to lengthen the amount of time that they have, if it were to be continued at home, it's really just going to kind of cause additional cost.

And additional logistical challenges.

And in many cases, when the hospices aren't able to provide that antibiotic, it kind of leads to delays.

And, and I've had far too many patients who, even though the stated goal was to return home, never make it home and never have that meaningful time with their family because of wanting to continue or feeling the need to continue IV antibiotics.

So we really want to provide for there to be ways where we explore Are we trying aggressive care for the prolongation of life?

Are we focusing more on comfort?

Or are we looking at a different mixture of values for trying to maximize a particular priority?

Like, let's say, meaningful time, alert and awake, and interacting with family.

And where are we in between that, and what goals can we have to guide us about how we direct antibiotic treatment?

And another scenario that kind of aligns with what we're talking about and that I've certainly encountered is when the medical team, the patient, and their caregivers or family are faced with a uncertain but likely poor prognosis, they're still deciding if recommended invasive intervention is the right fit for what they would desire.

And so you discuss what you termed as time limited trials in your paper.

And I was wondering if we could talk about that.

You know what components, if we are talking about something like a time limited trial, are important to make something that is well balanced, where we're, again, providing satisfaction that we're trying to exhaust all the interventions while also reducing the likelihood of inappropriate or sort of prolonged antibiotic courses.

Time limited trials is an effective strategy that any provider can pull out of the toolbox, and it's for the family who wants to exhaust all your options but still minimize the downstream effects of indefinite or undefined durations of antimicrobials.

So there's several elements to it.

It requires that one, you assess and define what the patient's preferences are for goals of care.

And then you have a predefined duration with predetermined clinical parameters that are objective so that you can measure them by and that is also communicated to the patient or patient's family.

And then the last component really needs to be where there needs to be follow up and reassessment and re evaluation of whether or not there was improvement or lack thereof for that specified duration.

And it allows the patient and the provider to be able to, as a compromise, to see whether or not to assess prognosis.

And then it gives you also validation whether or not antimicrobials is helping or not.

So I think it's a good compromise in, especially for those families who are not ready to withdraw or discontinue antibiotics completely.

So this is maybe the one of the more effective strategies.

It's been studied in ICU settings where it showed that if you were to do more formal meetings with the families and patient and follow up, the patients generally do have less aggressive ICU interventions where there might be minimal benefit.

So I think this is a good strategy to use in this type of setting.

I thought it was really helpful actually that in that box in your paper, you put a suggestion of two to three days for presumed bacterial fungal sepsis.

Because I think picking that duration with the team sometimes is, is hard.

I'm like, where do you start?

And what do you suggest?

So I actually thought that was quite useful.

I found that sometimes those shorter durations are harder to get everyone on board with, but I think is what we should be aiming for

because so often, you, you know, if it's really making a difference and you're really quite aware early on, if you're seeing those signs of improvement.

Yeah.

And it ends up sort of being, uh, I feel like negotiation is not the right word, but in some ways that's kind of what you're doing.

We started talking about this as well earlier, but these conversations about serious illness are obviously intertwined with really complex emotions, an individual's cultural experiences, and that's really for everyone involved.

Us as a medical team, the patients, their family members, I really appreciated how you walked through a lot of the examples of these emotions like guilt and indecision.

And I know that we can't cover all of that in this short podcast episode, but I was wondering if you could maybe talk just a little bit about some of these emotions and how we could be better prepared to respond to them.

Yeah, welcome.

I welcome ID colleagues to what the palliative folks do all day, is just deal with complex emotions all the time.

If I were to point to a couple of things there, I think one of the biggest reasons why we get into such challenging situations at the end of life is that we're really dealing with what feel like informational or cognitive questions or, or decisions.

Like, yes, I want antibiotics.

Yes, I want, or even like in the cases of like, yes, I want dialysis.

When really those are emotional decisions.

That's perhaps the, the, to crystallize so much of what we talk about in the article, that's what comes at the core.

Is that many times these are actually driven by emotion and not by a perhaps rational sense of this is the best treatment for my loved one at the very end of life.

It's this a sense of obligation or guilt if I don't treat them with antibiotics.

And I think when we pick up on that, when we are really hearing from families or patients that there's a sense of obligation to continue antibiotics as a feeling of needing to do everything, that we sometimes feel like they're rationally weighing everything.

They are rationally deciding that antibiotics are the best intervention for the loved one in this moment.

When in reality, they're probably coming from a place of, I don't want to fail them, or I want to give them every opportunity to continue thriving.

That's where, whenever possible, if we can intervene on the emotion or sort of pick up on that, this is an emotional issue going on and, and provide support in that way, it really does help to avoid a lot of the situations that we don't want to be in.

You know, guilt in particular is one of those where we can talk about just affirming everything that they've done for their loved one, trying to support them through an illness, advocating for them, trying to honor all of their wishes, but also really explaining why certain

interventions might only make the situation worse and relieving them from a sense of obligation in terms of having to provide that intervention.

So, we threw in some language there that not wanting them to feel that they have a, a, a deep obligation to keep doing treatments that they know aren't going to provide benefit.

And, and keeping a focus on the things that we can achieve that are more important, whether those are medical things or personal things.

If I could have everyone just read one table in any specialty, in any context, it's that table of, comes from the Quill article, the potential underlying meanings of do everything.

It is the, the article that I always go back to, if ever anyone tells me that they're struggling with managing end of life situations, I just tell them to read this article.

Because it really explores why is someone asking for doing everything?

Is it because they feel abandoned by the medical system?

Is it because they're concerned that, for totally valid reasons, that the medical system would not treat them fairly?

Is this fear?

Is this unresolved business?

It's all kind of in there.

And the more we can grasp what we think is going on, the more we can actually intervene directly on it.

Those are some of the big ones that we talked about in there.

It really is something that we would say, do it alongside a palliative colleague.

Come to us, ask us about it.

Let us know what you're thinking.

If you feel like there's an emotional piece going on, but you're not sure how to address it, find a palliative colleague and say, I think this is what's driving it.

I really think the antibiotics aren't going to be beneficial here, but I want some guidance on how to respond to the emotion.

And we're, we're really happy to help out with that.

I just want to say as an ID doctor who read this article many, many times, it's very, uh, yeah, this section on complex emotion is extremely insightful.

I especially like how there's very specific language that you can use and make those very specific examples.

Like I found very, very helpful.

Daisuke, this is just what I do all day.

This is just all day, every day.

I appreciate everything, all you do.

Thank you.

Before our palliative colleagues even get consulted, I see a lot of distress with, the intensivists or the hospitalists who continue antibiotics and don't have a defined parameter and they, and they want to continue it because, you know, you, the patient's family want to exhaust options

and they don't actually know what to measure that by, especially if, for example, there's low grade fevers intermittently from the tumor or whatnot.

So sometimes this is when I push for an infectious disease consult, just so maybe to give additional insight on some clinical parameters to measure as to when you should maybe consider stopping or at least some type of defined endpoint.

Um, also if there was a palliative consult for even maybe navigating the complex emotions of the , you know, the treating team, because it's all, for antimicrobial stewardship, it's often also navigating complex emotions of the treating providers, because they also have distress and guilt of withdrawing or discontinuing certain treatment options.

So, if, palliative care can also treat providers too, that would be helpful.

Complex emotions isn't just a course about the patient and I think the table that Dan had went into detail really helps the provider also navigate their own emotions too and how to address that with the patient.

It's a helpful and insightful table.

Yeah, I totally echo going in with colleagues and I feel like that's where I learned a lot of what language I use, is seeing other people model complex or difficult situations and being like, Oh, next time I'm going to phrase it that way.

Or I think we've all been in the room where like the other team comes in when you're like halfway through and asking for feedback on how you did and like how you could have done a little bit better, which can be uncomfortable.

But I, I do feel like many people are, are willing to do that because.

All of us can learn from how we talk to patients, which I think is a theme and just like you were saying in stewardship, talking to patients, really in anything even outside of end of life, but conversations about continuing antibiotics, particularly in patients that we know are transitioning to comfort care or hospice are another reason why often we're called.

Like maybe ID wasn't involved early on and this decision has been made and we sort of come in a little bit later.

And I have found that often there, you know, differing opinions and how beneficial antimicrobials are for quote symptom relief.

And, That is so important to inform how we explain risk benefit.

So I was wondering if you could talk a little bit about what we know in this space, like what's been published and any other sort of insight that you have.

Sure.

The quality of evidence about this topic isn't great, but at least from what we know, though, UTI seems to respond best to antibiotics with regards to symptom relief.

Depending on the study that you're looking at, the response rate, you know, might be even as high as like 90%.

Compare that to other infections, like, you know, pneumonia or soft tissue infections, or even like fever for bacteremia.

You know, the response rate probably hovers more kind of in the 20 50%, even like 0% in some cases.

So overall, you know, it seems reasonable to give antibiotics to treat UTIs for symptom relief, and also if the infection is clearly what's causing the symptom, like if someone has C.

diff diarrhea, or zoster, you know in those situations, it might be completely reasonable to just give antimicrobials try to help with the symptom management.

Pneumonia, I think it's probably worth talking about in itself, because it's probably what's uh, the most well studied in this kind of end of life setting.

The studies are a little bit mixed, but the concern with pneumonia is that, you know, there are studies that show, you know, increased survival with antibiotics, but no benefit, or even in my situation, antibiotics worsened their discomfort level.

So the concern is by giving antibiotics to these patients, we're just prolonging suffering.

And then there's also evidence to show that, you know, we can achieve good symptom control with other pharmacologic interventions as well.

So, one could definitely argue that you can use opiates for air hunger, or pain medications, or even antipyretics for fevers are much better interventions for symptom management than just giving antimicrobials.

So this was my afternoon yesterday, was walking into the room of a patient on comfort care who had just been transitioned the night before with pneumonia, on vancomycin and piperacillin tazobactam.

Being in this position again, we were, we're about to record this and I was thinking, my gosh, this is entirely relevant.

And we had to tell the family, you know, it, at this point, the antibiotics are not helping him breathe better.

They're not making him more comfortable.

The doses he's already had will do whatever they're going to do.

But continuing it is just actually extra fluid on his system that is going to result in more difficulty breathing.

Because he gets more pulmonary edema, it's going to just cause the side effects.

And it distracts from the focus of let's make him comfortable.

Let's make sure that he has the opioids that he needs, the breathing treatments that will help him feel better.

And really at this point, it isn't about the infectious process as it is about the secretions, the consolidation in the lung, all the other mechanics that are going on that are more inflammatory and don't have this infectious process going on.

It was so interesting because I could tell that sometimes we have this hesitation with a family who's so emotionally vulnerable in this moment saying, yes, this treatment is no longer necessary.

We're going to take this away.

One of the strategies that has helped a lot is to just, as we're taking something away that is no longer indicated, try to focus on what we're giving in return and say, we know that the vancomycin is not helpful.

Let's make sure that we're really aggressive in using our opioids to treat his shortness of breath.

We're really helping him feel more comfortable and less anxious with other medications too.

So that tends to help, I feel, with families that are really emotionally sensitive to that.

I'm glad you pulled out pneumonia specifically.

I think I was probably going to prompt and ask you about it.

That's perfect.

So, before we close out, I want to just give one more opportunity to either let you reinforce some take home points or perhaps add anything that you think we might have missed.

About a year ago, uh, Daisuke and I spoke at a Grand Rounds for Infectious Diseases over at Stanford, and the best question from one of, one of the members of the audience was, in looking at all these conversations about stopping antibiotics and, and having these goals of care conversations, the question in my mind is, do I have to?

And really the sense of this feels like a heavy lift.

This feels like a really heavy lift to say, I am going to take on these challenging conversations and make this a part of my practice.

And I really just want to stress that the point of this article wasn't to, wasn't to shame anyone or make them feel like you need to be doing this to better manage antibiotics at the end of life.

So the goal of this article was actually to say, if you're feeling moral distress around this, if you feel that there could be a better way of doing it, here's some strategies to try.

Some are easier to pick up, some take more practice and skill, but let's really think about the ways that we can improve our communication and meet patients and families where they are emotionally so that we're not using antibiotics to treat an emotional need.

We're actually really using them for their clinical indication.

That's, that's kind of the, the core piece of this is that this is meant to be tools to, to help take away the moral distress, not add to it.

I think that's especially relevant for like in an academic center because we might just be doing rotations.

We'll be on for like a week, see a patient this one time.

And then we'll just, we'll just sign off to the next provider, so that's probably part of the reason why we just, maybe having this conversation might feel like a heavy lift, but like what Dan said, you know, this, having these tools available, and then I think as infectious disease doctors or

palliative care doctors, if we collectively have all these tools, we can just, you know, enhance and better our patient care for this patient population.

There's, there's one other closing thought that's been on my mind as well, and that was I have the incredible privilege to attend these debriefings with the ID fellows here, talking about the cases they find challenging, the moral distress they might feel around cases, and it's so fascinating to me because more and more as I talk to the I.

D.

fellows, they tell me that the reason why they came into infectious diseases is for the social histories of their patients and getting to know them and understand them and explore their hobbies, their passions, because that's part of a good history taking.

What I came away with is, oh, there's this little palliative piece in these Infectious Diseases fellows that is deeply humanistic, and I walked away with such an appreciation for that.

Really, there's a core of this work that has an innate bond with patients, and I think the ways that we can honor that and help that and give additional tools for that, we really want to do.

So, I speak for the entirety of palliative care.

When I say call on us, we really want to collaborate and if you find yourself in a hallway talking with your colleague about moral distress, then find the ways to collaborate around that.

Our, yeah, our palliative care colleagues have really put a lot of perspective, at least especially in the past, I want to say five years with infectious disease division.

I remember really clearly where, like, infectious disease physicians sometimes do just center on just infection and don't think about the entirety.

I think one example that palliative and ID had discussed at a case conference was basically a patient who came in with invasive, you know, mucor who had to be redlined through surgery and potentially they had not explained that half of your face will potentially be surgically removed and what that would look like.

It's always to be able to step back and think about functionality and after the fact and what that would mean for the patient and the collaboration with infectious disease and palliative care is actually really important.

It provides perspective and then it doesn't really necessarily apply to a palliative like hospice patient, but in general, we do tend to just focus on our diagnostic and in our treatment options, but not necessarily always think about.

The whole picture, the moral distress that we have been experiencing, like the fact that we can have tools to reach out to, is really, it mitigates that.

So, mitigates that distress.

So, that's something that I wanted to highlight.

I have to give the biggest shout out to our co authors Ishminder Kaur, Emily Martin, Olivia Kates, and Tara Vijayan, who have been incredible.

It has really been such a fantastic process writing this article over, gosh, like a year and a half of many meetings, a lot of bonding, just a lot of also emotional processing in the time.

I'm so grateful.

It was really such a collaborative work of bringing two different specialties together in multiple disciplines.

And so I think we're all extremely proud of the work that we did and honestly, we could not have asked for better co authors in this situation.

Thank you so much to Dan, Christine, and Daisuke for joining Febrile today.

Super excited to have another STAR episode.

Don't forget to check out the website, febrilepodcast.

com, where you'll find the Consult Notes, which are written supplements to episodes with links to references, our library of ID merch store.

Febrile is produced with support from the Infectious Diseases Society of America, or IDSA.

Editing and mixing is provided by Bentley Brown.

Please reach out if you have any suggestions for future shows or want to be more involved with Febrile.

Thanks for listening, stay safe, and I'll see you next time.