Pneumonia in palliative care
Patients with palliative care needs who have frailty and advanced disease have an increased incidence of pneumonia.
Management of pneumonia in patients with palliative care needs is guided by the potential benefits and burdens of treatment, and the patient’s prognosis, preferences and goals of care—see Principles of symptom management in palliative care. Review the patient’s advance care plan and consider whether active treatment is likely to return the patient to their preferred quality of life. Pneumonia is a marker of poor prognosis in patients who require significant assistance with activities of daily living, who are bed-bound or immunocompromised, or who have dysphagia or aspiration. In these patients, death is common within a few weeks or months, even if antibiotics are used.
Pneumonia can cause discomfort from symptoms such as breathlessness, fever, chest pain, cough and increased respiratory secretions. Antibiotic therapy may improve comfort by decreasing breathlessness and respiratory secretions, and may prolong life. However, hospitalisation and intravenous antibiotic therapy may decrease comfort and cause confusion and distress.
Antibiotic therapy may not be indicated if the goal of care is symptom control without life prolongation. For these patients, treat symptoms such as breathlessness, respiratory tract secretions and anxiety or agitation—see also Principles of care in the last days of life.
If active treatment aligns with the patient’s preferences and goals of care, and pneumonia is expected to resolve, offer antibiotic therapy (see Finding the right pneumonia topic in the Antibiotic guidelines). In addition to antibiotic therapy, consider management of symptoms such as breathlessness, cough (including nondrug interventions such as Active Cycle of Breathing exercises), or delirium, if needed.
Review patients after 24 to 48 hours of antibiotic therapy:
- if there is no improvement, reassess the diagnosis (see Approach to managing adults with CAP who are not improving in the Antibiotic guidelines)
- if the patient has worsened, reconsider the patient’s prognosis, discuss the goals of care and consider escalating active management. Alternatively, withdraw antibiotic therapy and focus on symptomatic management and supporting the patient and their family—see Principles of care in the last days of life).