Antibiotic Use at the End of Life: Balancing Symptom Relief, Treatment Burden, and Stewardship

Abstract

Background: Antibiotic use remains common among patients receiving palliative and end-of-life care despite limited evidence that treatment consistently improves patient-centered outcomes. Clinicians frequently face uncertainty when balancing potential symptom relief against treatment burden, antimicrobial resistance concerns, and alignment with patient goals of care. Evidence Sources: A structured narrative review was conducted using studies identified through searches of major biomedical databases and reference screening, including observational cohorts, qualitative studies, and reviews addressing antimicrobial use across hospice, hospital, community, and long-term care settings. Findings: Antibiotics are frequently prescribed during the final weeks of life, often without confirmed infection. Symptom benefit varies substantially by infection type; evidence for benefit is strongest for sepsis (approximately 50% response), while urinary tract infections show considerably lower benefit (approximately 17%), and respiratory or source-unclear infections show even less consistent improvement. Treatment burdens include adverse effects, intravenous access discomfort, hospital transfer, and antimicrobial resistance risks. Conclusions: Antibiotic prescribing near the end of life should prioritize patient goals, expected symptom benefit, and minimized treatment burden while incorporating stewardship and shared decision-making strategies.