Q&A: What is the ID clinician’s role in end-of-life care?
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Key takeaways:
- Within the Duke University Health System, the number of ID consults increased by 94% over the last decade.
- Researchers said ID physicians are now providing care for more complex and sicker patients.
Patients receiving infectious diseases consultation over the past decade were increasingly complex, generally sicker and more likely to die soon after a consultation was performed, according to a study.
Researchers said that the rate of infectious diseases (ID) consultation relative to hospital admissions doubled during that time, suggesting that ID physicians are more often being faced with the challenge of caring for complex patients.
Because of this, Alison G.C. Smith, MD, MSC, and Jason E. Stout, MD, MHS, and colleagues aimed to assess the role of these physicians when it came to end-of-life care, leading them to conduct a retrospective cohort study of all patients with an ID consult at the Duke University Health System between Jan. 1, 2014, and Dec. 31, 2023.
In total, 60,820 inpatient ID consults were assessed, which showed that the number of consults increased by 94% and the rate rose from five to 9.9 consults per 100 inpatients (P < .001) over the course of the study. Additional data showed that 7.5% of patients who received an ID consult died during admission, whereas 2.6% were discharged to hospice.
Among all patients, in-hospital mortality was 5.2% for community ID, 7.8% for general ID and 10.7% for ID patients who have undergone transplant (P < .001). The study also showed that 6-month mortality was 9% for all nonobstetric admissions vs. 19% for community ID, 20.9% for general ID and 22.3% for transplant ID.
In total 2,866 (7.6%) of all patients receiving ID consultation also received palliative care consultation during the same hospitalization.
We spoke with Smith, a junior assistant resident at Duke University School of Medicine, and Stout, a professor of medicine at Duke University School of Medicine, about the role of ID clinicians in end-of-life care and how they are focusing more on “the big picture,” while optimizing quality of life and comfort care of these patients.
Healio: What prompted this study?
Smith and Stout: The study was prompted by an impression on the part of ID clinicians at our center that we were being consulted more frequently on patients who were sicker and more likely to do poorly. We felt that we were doing a lot more palliative care on our inpatient services, but there was no objective data to support that feeling. The study was driven by the desire to better quantify and understand these impressions.
Healio: What is the ID clinician’s role in end-of-life care (including and in addition to antimicrobial management)?
Smith and Stout: The answer to this question is evolving. In the pre-antiretroviral era, ID physicians were very involved in palliative care for their patients with advanced HIV infection. Since the advent of effective antiretrovirals, this has become a much smaller part of ID practice.
However, multiple societal forces including the obesity epidemic, the opioid epidemic, and availability of advanced technologies that keep patients alive who would have previously died (such as extracorporeal membrane oxygenation and left ventricular assist devices, to name a couple) have resulted in a sicker inpatient population who frequently require ID consultation.
Because ID physicians tend to be holistic, they often consider the “big picture” when consulted and consider whether interventions such as antimicrobials are likely to improve quality and quantity of life. A key function of the ID physician is to help patients and clinicians make informed decisions about whether antimicrobial therapy is going to provide a curative or palliative role for a given patient, and implicitly to avoid giving antimicrobial agents to patients for whom they will not be helpful.
Healio: Is there training available for ID clinicians in this area?
Smith and Stout: We are not aware of any formal training within the ID realm, although there is the option to pursue a second fellowship in palliative care.
Healio: What’s something about ID and end-of-life care that might surprise readers?
Smith and Stout: ID clinicians are often consulted when patients are actively dying because their providers fear “not doing everything” for the patient. The advice that is frequently provided is not to administer antibiotics but to focus on the big picture and on appropriate measures to optimize quality of life, including comfort care.
Healio: What is the clinical take home message?
Smith and Stout: ID physicians are busier than ever treating sicker patients in the hospital who are more likely to die. This may lead to burnout among existing ID physicians and present challenges to recruiting physicians to train in ID. Both the ID specialty and the U.S. medical system as a whole will need to address this challenge to ensure a healthy and vibrant ID workforce.
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