Life-Sustaining Technologies -- Antibiotics

The discovery of antibiotics has been described as the greatest life-saving technological development in the history of modern medicine. Despite the frequent success of antibiotics in reversing life-threatening infections, infectious diseases remain a serious problem for elderly people. At a time when medical technologies can support body functions almost indefinitely, severe infection is still a challenge when infections account for approximately 30 percent of all deaths in the elderly population.

Although antibiotics are usually effective in the treatment of infections, these drugs cannot cure underlying diseases or disabling conditions that are common among elderly persons. In some persons, a life-threatening infection is superimposed on a terminal illness or an incurable, severely debilitating, chronic disease. Some healthcare providers believe that in some cases the use of antibiotics to treat an infection prolong the dying process or prolongs the patient's suffering unnecessarily.

Some of the life-threatening infections that commonly affect elderly people are: bacterial pneumonia, urinary tract infections, infected decubitus ulcers (bed or pressure sores), and introgenic infections that sometimes result from the use of medical devices. Any local infection in a seriously ill older person, however, can rapidly spread and become life-threatening.

Various risk factors make older people vulnerable to infection and include:

1. Hospitalization -- People are exposed to a large number of agents that can cause infections. Nosocomial (hospital-acquired) infections are often fatal, in part because they are frequently caused by agents that are resistant to antibiotics.

2. Communal living -- The common use of urinary catheters and other factors often associated with nursing home care, foster infections.

3. Diminished immune function -- Aging, various diseases, some medical treatments, and inadequate food and fluid intake that may result from poverty, depression, forgetfulness, mobility impairments, illness, or medical treatments that decrease appetite can result in reduced immune function.

4. Life-sustaining medical devices -- Mechanical ventilators, dialysis equipment, and other devices used to provide total parenteral nutrition can increase the risk of infections.

Antibiotics are a large set of drugs use to cure or control numerous bacterial, viral, and fungal infections, including minor ones. Different families of antibiotics have been developed for use in combatting different types of infections. Antibiotics may be administered topically, orally, intravenously, or intramuscularly, in discrete doses or continuously. All antibiotics are potentially life-sustaining.

Except for antibiotics, none of the five life-sustaining technologies discussed in this article cure the underlying condition that precipitated its use. Thus, among patients who receive these interventions and survive, health status and functional capacity vary widely. While some patients regain adequate natural function of the affected organ, others become permanently dependent on the life-sustaining technology (and they may be simultaneously dependent on more than one life-sustaining technology). They may require continuous medical care and, often, other forms of assistance.

Antibiotics generally are successful in combating most types of infections, with patients showing improvement within a few hours or days, and complete cure within a few days or weeks. With older persons, the outcome of antibiotic treatment for life-threatening infections are often unpredictable.

However, antibiotic therapy is especially important for chronically ill older people receiving long-term mechanical ventilation, dialysis, or nutritional support. Without antibiotic treatment of the iatrogenic infections often associated with these technologies, it would be impossible to restore these patients to a clinically stable condition. Antibiotics enable these other technologies to sustain lives.

Antibiotics are the least complex and least expensive life-sustaining technologies. Because physicians consider antibiotics ordinary or standard treatment, their decisions to use them in the treatment of life-threatening infections are often automatic. Clinic criteria, rather than patient's or surrogate's wishes, are often their primary considerations. In addition, many elderly patients being considered for life-sustaining antibiotic treatment are severely debilitated and incapable of making treatment decisions. Decisionmaking aids like the living will are rarely of use to these people, who often have been incapacitated for a long time and are unlikely to have given specific prior directives regarding their care.

Antibiotics are usually effective in curing infections. However, they can neither eliminate nor alleviate preexisting illness in chronically, critical, or terminally ill or severely debilitated elderly people. Many health care providers believe that antibiotic treatment is always appropriate when an active infection is present.

Despite this strong presumption in favor of using antibiotic therapy, some health care providers and other believe that there are circumstances in which it is justifiable to withhold life-sustaining antibiotic treatment. For example, one physician told about his 96-year-old mother who experienced two strokes a week apart and developed pneumonia. The woman's children asked the hospital staff not to treat the pneumonia, but the staff insisted they could not "do nothing," and she was given antibiotics. She ended up in a nursing home in a semivegetative state, she lost her functional and mental independence. Everything she wanted to avoid has happened to her.

Information for this article on life-sustaining technologies was excerpted from a study by the U.S. Office of Technology Assessment (OTA).