End-of-life decision-making often is a complex process, even more so if patients develop an infection.
To learn how infectious complications affect goals-of-care decision-making, researchers reviewed 232 trauma patients without advance directives who were labeled “comfort measures only.”1 Of this group, 72 developed an infection (most commonly, pneumonia).
“It seemed to us that many people think that infections are always curable with the help of antibiotics,” says Stephanie Lueckel, MD, ScM, FACS, one of the study’s authors and section chief of trauma at Rhode Island Hospital.
Lueckel and colleagues wanted to know if people considered infections as a serious enough setback, it would speed their decision to withdraw life-sustaining treatment. They did find this to be the case.
“Our results speak to the fact that infections may not be viewed as a significant complication,” says Elizabeth Tindal, MD, MPH, BA, the study’s lead author and a surgical resident at Rhode Island Hospital’s division of surgical research.
People often assume antibiotics are a simple solution to infectious complications, which is not always the case. “As providers, this may reflect on how we counsel patients and family members on the clinical significance of infections and how they relate to injury severity and a patient’s baseline health status,” Tindal says.
Clinicians “really need to explain the downstream effects of traumatic injuries and ICU care to families in detail so they can see how each bump in the road will affect the patient,” Lueckel says.
Contracting pneumonia is one thing; treating pneumonia in a patient with rib fractures, pelvic fractures, traumatic brain injury, and hemorrhagic shock is another. “This concept is difficult for families to understand,” says Lueckel, associate professor of surgery at Warren Alpert Medical School at Brown University
Clinicians can prevent end-of-life conflicts with goals-of-care discussions shortly after high-risk patients are admitted. This way, a plan of care is established in line with the patient’s wishes from the beginning, and providers can set expectations for curveballs such as infections.
Still, some people will reject withdrawal of life-sustaining treatments regardless of the clinical situation. “Provider counseling needs to be tailored to their perspectives and values,” Tindal offers.
Infections are common among ED patients and often affect end-of-life decision-making. “Some infections are easily treated, and treatment may result in comfort and dignity,” says Catherine A. Marco, MD, FACEP, a professor in the department of emergency medicine at Wright State University in Kettering, OH.
Examples might include patients with a urinary tract infection or cellulitis. However, more invasive or complex infections might require invasive or painful interventions, such as bilateral pneumonia with respiratory failure, requiring intubation and ventilatory support.
“In cases where aggressive interventions are not in accordance with patient wishes, comfort measures should be provided, including pain control, noninvasive respiratory support, and social and religious support,” Marco says.
- Tindal EW, Heffernan DS, Kheirbek T, et al. Adding infectious insult to traumatic injury: The impact of infectious complications in end-of-life decision making. Surg Infect (Larchmt) 2021;22:884-888.