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Antibiotic Treatment at End of Life: When Is It Appropriate & How Do We Discuss It? · The SHEA Podcast

• 0:09
  SPEAKER_02: Welcome to the Infection Prevention and Antibiotic Stewardship End of Life podcast series brought to you by the Society for Healthcare Epidemiology of America, SHA, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:26
  SPEAKER_02: I'm Dr.
• 0:26
  SPEAKER_02: Haley Pritchard, Assistant Professor of Clinical Medicine at Indiana University School of Medicine and Medical Director for Antimicrobial Stewardship at the Indiana University Health Adult Academic Medical Center, and I will serve a city's moderator.
• 0:39
  SPEAKER_02: Shay is excited to launch this episode of the podcast series entitled Antibiotic Treatment at the End of Life.
• 0:44
  SPEAKER_02: When is it appropriate and how do we discuss it?
• 0:46
  SPEAKER_02: Our discussion today will explore the role of antibiotic treatment at the end of life studying with a focus on balancing the role in maintaining comfort and relieving symptoms with a concern for adverse effects, excessive or futile use, and contribution to the development of antibiotic resistance.
• 1:01
  SPEAKER_02: In addition, we'll talk about how to approach the appropriateness of antibiotic use for patients in end-of-life care and their families.
• 1:07
  SPEAKER_02: I'm happy to introduce our speakers for today.
• 1:09
  SPEAKER_02: First, we have JJ Peruno, epidemiologist, and a professor in the Oregon State University College of Pharmacy in Portland, Oregon.
• 1:15
  SPEAKER_02: He's primarily a researcher and engaged multiple studies focused on optimizing medication use and nursing home residents and patients at the end of life.
• 1:23
  SPEAKER_00: Hi, thanks for having me.
• 1:24
  SPEAKER_02: Thank you for being here.
• 1:25
  SPEAKER_02: Next, we have Susan Mitchell, professor of medicine at Harvard Medical School and senior scientist at the Hinda and Arthur Marcus Institute for Aging Research at Hebrew Senior Life in Boston, Massachusetts, where she directs a palliative care and aging research center and co-directs the Interventional Studies and Aging Center.
• 1:40
  SPEAKER_02: Dr.
• 1:41
  SPEAKER_02: Mitchell is a geriatrician and health services researcher, and her research focuses on improving outcomes for older patients with advanced illness, particularly those with dementia.
• 1:48
  SPEAKER_02: Hi, great to be here.
• 1:50
  SPEAKER_02: Thank you all for joining us.
• 1:51
  SPEAKER_02: Let's jump right in.
• 1:52
  SPEAKER_02: I'll direct this first question to JJ.
• 1:54
  SPEAKER_02: When do you think antibiotics might be appropriate for patients in end-of-life care?
• 1:59
  SPEAKER_00: So I guess just, you know, a clarification and just thinking about who end-of-life, who's receiving end-of-life care.
• 2:04
  SPEAKER_00: And I think I suspect Susan will add to this.
• 2:08
  SPEAKER_00: You know, it's just, you know, are we thinking about hospice patients?
• 2:10
  SPEAKER_00: Are we thinking about patients who are actively dying?
• 2:12
  SPEAKER_00: Uh, are we thinking about residents of nursing homes with advanced illness and limited life expectancy?
• 2:18
  SPEAKER_00: So I I think there's a lot of it depends with respect to this question.
• 2:22
  SPEAKER_00: Generally, my answer would be when the benefits outweigh the risk.
• 2:26
  SPEAKER_00: You know, when you're evaluating what the potential benefits would be, and you know, ideally these are well aligned with the patient and family goals of care, then I think antibiotics can be indicated in in this patient population.
• 2:38
  SPEAKER_00: But as I'm sure we'll discuss, you know, I think elucidating some of those things is very, very challenging in in this patient population.
• 2:45
  SPEAKER_00: But there are some ways that you can hopefully do that.
• 2:47
  SPEAKER_00: So I guess the short answer is it depends.
• 2:49
  SPEAKER_00: But also I do think um when when the benefits out outweigh the risks, um, which is pretty obvious.
• 2:54
  SPEAKER_01: Thank you.
• 2:55
  SPEAKER_01: Dr.
• 2:55
  SPEAKER_01: Mitchell, would you care to comment?
• 2:57
  SPEAKER_01: Well, I think it's an interesting point JJ brings up as sort of what is end-of-life care, and maybe it's a bit of terminology.
• 3:03
  SPEAKER_01: When I think about this issue, the question to me really, it's not so much how far someone is from the end of life, because sometimes that's really actually hard to predict.
• 3:13
  SPEAKER_01: It's really about when it's appropriate for people who may be in a terminal stage of a disease, or really about when their goal of care is primarily comfort.
• 3:22
  SPEAKER_01: Someone could be someone with advanced dementia and six months away from the end of life, but their goal is still really palliative care.
• 3:29
  SPEAKER_01: And so if I sort of reframe the question slightly, is when do you think antibiotics may be appropriate for people?
• 3:35
  SPEAKER_01: Um, well, I guess people at the terminal stage of an illness.
• 3:39
  SPEAKER_01: And I think two factors need to be in place and be considered.
• 3:42
  SPEAKER_01: One, does the person really show the signs and symptoms of a true bacterial infection?
• 3:49
  SPEAKER_01: Because too often antibiotics are considered empirically for people who might look a little off that day, who's not eating as much, et cetera, et cetera.
• 3:58
  SPEAKER_01: And Shay does have some guidance about uh when signs and symptoms really support a bacterial infection, if the clinician, and that requires a proper assessment, and even that's even before, you know, cultures or x-rays, uh, et cetera.
• 4:13
  SPEAKER_01: So it's more than just looking a little off one day.
• 4:16
  SPEAKER_01: And then the second part to it that needs to be explored simultaneously is if the clinician really thinks there's a bacterial infection going on that might be responsive to antibiotics, is how does the treatment align with the goals of care?
• 4:31
  SPEAKER_01: Most people towards the end of life want more comfort care.
• 4:34
  SPEAKER_01: If that is the goal of care and the symptoms of the supposed infection is really causing discomfort, then that might be indicated.
• 4:43
  SPEAKER_01: If the person's still opting for some life prolongation, uh even if at that, you know, if they're willing to accept some uh uncomfortable treatment towards that, then yeah, antibiotics probably will meet those goals of care for that person for the short time.
• 4:58
  SPEAKER_01: So one, I short answer, is there truly a bacterial infection by signs and symptoms?
• 5:03
  SPEAKER_01: And two, does the antibiotic meet the goals of care or not?
• 5:07
  SPEAKER_01: I think those are the two check boxes.
• 5:09
  SPEAKER_02: As a steward, I always love to hear the discussion of is there an infection that requires treatment before even considering antibiotics?
• 5:16
  SPEAKER_02: So I I love and appreciate that that aspect of your answer.
• 5:20
  SPEAKER_02: Thank you both for your answers.
• 5:21
  SPEAKER_02: I think that there is a lot to consider in this patient population.
• 5:24
  SPEAKER_02: And you're absolutely correct that there is a huge spectrum of what end-of-life care means.
• 5:29
  SPEAKER_02: Do you think that IV antibiotics are ever appropriate for patients on hospice specifically?
• 5:34
  SPEAKER_02: Susan, if you wouldn't mind taking this one first.
• 5:36
  SPEAKER_01: So I think IV antibiotics are appropriate for a person on hospice.
• 5:40
  SPEAKER_01: So if somebody is on hospice, then presumably their goal of care is comfort.
• 5:45
  SPEAKER_01: And so again, I always sort of think backwards from there.
• 5:49
  SPEAKER_01: Again, there should be enough criteria, minimal criteria to meet the likelihood of a bacterial infection.
• 5:55
  SPEAKER_01: And if the goal of care is comfort, and there's a real belief that these IV antibiotics that can't be administered any other way will promote comfort, then yes, otherwise, no, because you know the IV itself can be uncomfortable and uh has the all the side effects that we know they can have.
• 6:14
  SPEAKER_01: So I'm trying to actually go through my mind and think about a situation when IV antibiotics specifically would make someone more comfortable.
• 6:22
  SPEAKER_01: It's it's hard to think of an instance, actually.
• 6:26
  SPEAKER_01: But uh, you know, conceptually it would have to meet those two criteria.
• 6:30
  SPEAKER_01: Thank you.
• 6:31
  SPEAKER_02: And JJ.
• 6:32
  SPEAKER_00: I totally agree with Susan.
• 6:34
  SPEAKER_00: A lot of my work has been in hospice and also in people transitioning to hospice.
• 6:39
  SPEAKER_00: When we first were interested in these questions, and we would go and talk to hospice providers about why there seems to be a lot of antibiotic use in this patient population, and they and they would tell us, well, they're already on antibiotics when they when they enter hospice.
• 6:52
  SPEAKER_00: So they they show up at hospice, you know, with with this antibiotic prescription.
• 6:56
  SPEAKER_00: And so I guess the reason why I bring this up is because stopping these antibiotics necessarily, or if you know, the if you feel like this could be a barrier to hospice entry, sometimes people, you know, I think people will often say, if this can help me, I want it.
• 7:09
  SPEAKER_00: And we don't always know if it can help them.
• 7:12
  SPEAKER_00: But you know, entering hospice is is a typically a good outcome, at least in my from my perspective.
• 7:17
  SPEAKER_00: This is something that's going to help people die more comfortably in a setting where I think they're uh with their families and typically demedicalized.
• 7:25
  SPEAKER_00: And so I guess I can imagine a scenario where they may still be on this line hasn't been pulled when they show up at hospice and they may just let them finish something.
• 7:33
  SPEAKER_00: But uh, you know, beyond that, I completely agree with Susan about difficult to imagine a scenario under which this would actually get started once people have entered hospice.
• 7:42
  SPEAKER_01: Just to again reiterate something is if someone's in hospice, their goal of care is comfort.
• 7:48
  SPEAKER_01: And I I think we should remember too that there are things we do to keep people comfortable besides antibiotics, and those should be made clear to the families.
• 7:57
  SPEAKER_01: And so it's not that you're withholding treatment, you're giving treatment that's an alternative to antibiotics, and it could be um obviously pain medication or swabbing your mouth or whatever oxygen for if someone has a lot of congestion or sputum.
• 8:13
  SPEAKER_01: And so it's important, and there actually has never been a head-to-head RCT of whether, let's say, someone has a true blown pneumonia and is at the end of life or in hospice, whether antibiotic versus these palliative uh symptom-focused treatments improve comfort more than one or the other.
• 8:32
  SPEAKER_02: Part of why Shay is discussing this is that the impact of antibiotic overuse on antimicrobial resistance is a global concern with potentially devastating consequences.
• 8:41
  SPEAKER_02: So, what do you you perceive are the risks or downsides of antibiotic use in the setting for both the individual patient and the wider population?
• 8:49
  SPEAKER_02: Susan, how about you start us off?
• 8:51
  SPEAKER_01: So, I mean, this is this issue of um use or inappropriate use of antibiotics and antimicrobial resistance as it applies to um end-of-life care is really super important because up to now we've been talking about weighing the benefits and burdens for an individual patient.
• 9:09
  SPEAKER_01: But as everybody knows, the you know, four ethical principles.
• 9:13
  SPEAKER_01: The last one is one of justice, which relates to what makes sense for the wider society.
• 9:19
  SPEAKER_01: And I think if giving inappro antibiotics either when they're not indicated or not meeting goals of care and so used inappropriately are contributing to antimicrobial resistance, we're undermining the ethical principle of justice.
• 9:33
  SPEAKER_01: And I so it becomes a societal issue in addition to the individual issue.
• 9:38
  SPEAKER_01: I know in the population I study the most, people with advanced dementia living in nursing homes, we did a prospective study and of people with advanced dementia and watched them for a year.
• 9:48
  SPEAKER_01: And those who started without an antimicrobial resistance, by the end of the study, 40% of those had a resistant bacteria.
• 9:56
  SPEAKER_01: And overall, 60% over the course of the study had a resistant bacteria.
• 10:00
  SPEAKER_01: And this is much, much higher than other resident populations of nursing homes.
• 10:04
  SPEAKER_01: And of course, they spread to other people and they bring them into hospitals, and so it's a it's a an important consideration here.
• 10:12
  SPEAKER_02: Thank you.
• 10:12
  SPEAKER_02: And JJ, what are your thoughts?
• 10:14
  SPEAKER_00: I agree.
• 10:14
  SPEAKER_00: I mean, I think we we know that you know overuse of antibiotics can lead to resistance.
• 10:18
  SPEAKER_00: And and you know, when I first entered this area of research, it was to see, you know, I think the kind of the hypothesis was, because there was not a lot of information, was just that there's a lot of antibiotic use in a setting where there's probably not a lot of resources and evidence to support that type of use.
• 10:34
  SPEAKER_00: And so, but there really hadn't been a ton of work actually estimating that prevalence.
• 10:39
  SPEAKER_00: I think when we um first looked at this using, and these data are now old, but I think it was the NHHCS data from 2007, it was around 27% of patients received antibiotics in in the final week of life.
• 10:51
  SPEAKER_00: And I think we are kind of amazed by that number.
• 10:54
  SPEAKER_00: I think you're gonna see that it's actually much higher in other what could be considered end-of-life populations than that.
• 11:00
  SPEAKER_00: You know, I I really worry about this idea of people like either leaving hospice because they're not feeling like I mean, I so I completely agree with Susan that there there are other ways to treat these symptoms, and we don't, you know, actually have good RCT data or any RCT data that actually show that in the hospice setting.
• 11:18
  SPEAKER_00: But you know, I I worry about, certainly worry about antibiotic selective pressure.
• 11:22
  SPEAKER_00: I I think we want to make sure that people are making an um an informed decision regarding, I think there's an assumption that antibiotics are benign and they're definitely going to help them when when in fact we all know that there's a number of potential adverse events that are probably more likely maybe than actually either resolution of their symptoms or of their of their infection.
• 11:40
  SPEAKER_00: But trying to just balance all of these things with, you know, and whether or not it makes sense to actually start antibiotics can be tricky.
• 11:46
  SPEAKER_00: So I guess I understand if a clinician is going to start antibiotics if they feel like they're warranted and they feel like the benefits outweigh the risks and these align with the goals of care, treating their symptoms in hospice.
• 11:57
  SPEAKER_00: But of course, we want to minimize as much, if not all, inappropriate use of antibiotics, certainly not in the setting where there's actually not a true infection, or we don't think they're going to be beneficial, or where the risks outweigh the benefits.
• 12:09
  SPEAKER_00: And one of those clear risks is the is the societal issue of increasing antibiotic selective pressure and increasing the pool of resistant organisms.
• 12:18
  SPEAKER_02: And it can be very hard to discuss or impress impress that upon patients and families, especially in a in such a stressful time for both for both patients and their loved ones when someone is receiving end-of-life care.
• 12:31
  SPEAKER_02: And we all we know that lots of patients and their families might have different values when it comes to antibiotic use during this period.
• 12:37
  SPEAKER_02: How would you talk about whether or not to recommend antibiotics with your patients and their families?
• 12:43
  SPEAKER_02: JT, would you like to respond first?
• 12:45
  SPEAKER_00: Sure.
• 12:45
  SPEAKER_00: There are lots of tools for talking to people about antibiotic use.
• 12:49
  SPEAKER_00: I think one of the things that you learn when you try to understand antibiotic use in hospice, as I mentioned earlier, is that often people have have already started on antibiotics earlier.
• 12:58
  SPEAKER_00: And I think more and more what we learn is that you want to start talking to people about these things as far upstream as you can, where at least they still can envision to the best of their ability what their decisions may be when obviously their condition worsens and the, you know, and then you adjust these decisions accordingly.
• 13:13
  SPEAKER_00: So everything that I think we learn about transitions of care, everything that we is that we should have thought about this earlier and talked to people about this earlier, thinking about what people's goals of care are, documenting this.
• 13:24
  SPEAKER_00: There's there's a number of tools about, you know, and in Oregon is well known for using Pulsed, which I believe still stands for physician orders for life-sustaining therapy.
• 13:35
  SPEAKER_00: But uh many other states have have these forms.
• 13:38
  SPEAKER_00: Antibiotics actually used to be an individual field on the Oregon Pulse form, but it's um my understanding now is um I haven't looked at the most recent form, is that it's now included with other types of intensity of medical interventions.
• 13:50
  SPEAKER_00: But the the reason to bring this up is because this is a tool where you can ask people, you know, as when you are now have a life-limiting illness, do you want to receive antibiotics?
• 14:00
  SPEAKER_00: I do think it still comes down to if this can help me, I want it, you know what I mean?
• 14:04
  SPEAKER_00: And help me may mean alleviating my symptoms, or help me maybe this is gonna help me live longer, but not maybe not better.
• 14:11
  SPEAKER_00: So I think that this can be this can be very tricky.
• 14:14
  SPEAKER_00: And I think a lot of times people assume that hospice should handle this.
• 14:18
  SPEAKER_00: And I think that's absolutely wrong.
• 14:20
  SPEAKER_00: You know, hospices are clearly trained to talk to people about these things, but but people have their trusted medical providers, and and all medical providers, primary care providers, should be able to talk to people about serious illness, about you know, the risks and benefits of medications depending upon their, you know, the situation, helping with care coordination.
• 14:37
  SPEAKER_00: We call this primary palliative care.
• 14:39
  SPEAKER_00: And all really all, I mean, I'm not a medical provider, so I don't like telling medical providers necessarily what they should and should not know.
• 14:44
  SPEAKER_00: But that being said, these competencies should it should really be present for people taking care of other people and um being able to at least start this process.
• 14:52
  SPEAKER_02: I agree.
• 14:53
  SPEAKER_02: Um, as someone who practices in a very complex patient population, I'm sometimes surprised by the fact that these conversations have not taken place by the time I'm seeing the patient in the hospital.
• 15:04
  SPEAKER_02: Susan, what are your thoughts?
• 15:06
  SPEAKER_01: Yeah, so I I think you know this is a conversation.
• 15:09
  SPEAKER_01: So the pulse forms are great if they have it, but just to ask someone, do you want antibiotics is not the contextual conversation that should be having.
• 15:18
  SPEAKER_01: So I approach us much like I approach any other sort of decision-making rubric.
• 15:24
  SPEAKER_01: And again, one would have to differentiate is this a discussion that's taking place in advance of clinical situation, or is it the middle of the night conversation for the family of a nursing home resident who spikes a fever?
• 15:36
  SPEAKER_01: But either way, I think the first I sort of have a bit of a stepwise approach where first I try to undersee and educate the family as much as I can about what is the clinical situation of their person, that they're near the end of their life and that this is a potential infection, but to understand where they are in the course of their broader disease trajectory.
• 15:58
  SPEAKER_01: And then I do try to at first have them before I launch in do you want antibiotics, articulate what the goal of care is once I know they understand the clinical situation.
• 16:07
  SPEAKER_01: And then I think we want an informed decision about antibiotics.
• 16:11
  SPEAKER_01: And so I would try to outline the some sort of evidence-based discussion about what are the potential benefits and risks of antibiotics.
• 16:20
  SPEAKER_01: Um, so for example, if it's a potential UTI, we know that probably won't prolong life, et cetera.
• 16:25
  SPEAKER_01: And so I then try to harmonize for the family the risks and benefits from an evidence point of view with their goals of care.
• 16:33
  SPEAKER_01: And then I once I know that I've had a good quality discussion about the prognosis where they are and the risks and benefits of the treatment options, I'll ask them what they think.
• 16:44
  SPEAKER_01: And I think the format of your question is very interesting, whether or not to recommend antibiotics.
• 16:50
  SPEAKER_01: In some so much of these discussions, we go, okay, so now that I've told you this, what do you want?
• 16:56
  SPEAKER_01: And I'm not sure that's the right way to be.
• 16:58
  SPEAKER_01: And I actually usually say, would you would you like my recommendation or something like that?
• 17:03
  SPEAKER_01: The point is it's a discussion, and I think it has to be an informed discussion.
• 17:07
  SPEAKER_01: And there's one other point I will bring up here is the issues of disparities because we know people, uh least in nursing homes, non-white residents tend to get more aggressive care.
• 17:18
  SPEAKER_01: And my belief and some evidence shows is that part of the problem is providers come in different ways to the table to people of color and different people, and this quality of counseling is not done quite as well with people of lower health literacy or who are non-white.
• 17:34
  SPEAKER_01: And so it's really important, I think, to have some standardized rubric to approach people from all backgrounds and so that we can even the playing field in terms of the counseling and give everyone the opportunity for making the best, most informed decision.
• 17:48
  SPEAKER_02: I actually really love your suggestion of explaining people what the risk and benefits different options are and then asking them what they want.
• 17:56
  SPEAKER_02: So many patients and families are in a state of decision fatigue getting to this point that I think that offering a recommendation may may help alleviate that also.
• 18:06
  SPEAKER_02: As a steward, I often find that we as providers sometimes use antibiotics as anxiolytics for ourselves rather than for our patients.
• 18:14
  SPEAKER_02: Do either of you have any suggestions as far as what providers can do to better navigate this issue?
• 18:19
  SPEAKER_02: And I'll start with you, Susan.
• 18:21
  SPEAKER_01: Well, the first thing I would do is slow down.
• 18:23
  SPEAKER_01: And this is tough because it's not only angelic but it's angiolytic, but it's sometimes like in a busy nursing home setting the path of least resistance and easiest, fastest thing to do.
• 18:33
  SPEAKER_01: So I think the first thing the onus is for providers, the easiest thing to do is or the most intervenable piece is to provide some education for providers, not just about what constitutes uh signs and symptoms of a bacterial infection, so the infectious disease type of best practices, but also provide tools for them in terms of best practices of having these conversations with families and understanding how goals of care play into this, in addition to understanding uh the evidence, because I can tell you, even now, with all the work that's been done by the CDC, etc., there's still lots of providers in nursing homes who still think you give antibiotics for dark or malordorous urine.
• 19:15
  SPEAKER_01: So there's a lot of education to do up front and give uh providers the tools to, as you say, help navigate this issue better.
• 19:24
  SPEAKER_01: And then again, I would advise them to sort of slow down, sometimes take a watch and wait approach and also, you know, really give them tools to talk to families because sometimes they're just getting really pressured by families around this issue.
• 19:38
  SPEAKER_01: JJ, what are your thoughts?
• 19:40
  SPEAKER_00: I agree that education is is a there's a huge deficit, and it would be very helpful and effective, I think, to provide more education for providers and thinking about this, and also how how to engage in these conversations, which again, I think people are definitely not comfortable.
• 19:55
  SPEAKER_00: I I do think that's the other piece, is really pushing this primary palliative care responsibility and for clinicians to be more proactive in starting these conversations.
• 20:05
  SPEAKER_00: You know, we've done research at OHSU, which is where I do a lot of my work here in Portland.
• 20:10
  SPEAKER_00: And for one study that we did, more than half aren't able to engage in their own goals of care conversations on that encounter.
• 20:16
  SPEAKER_00: So this needed to happen before that encounter.
• 20:19
  SPEAKER_00: And so, you know, I think when patients are diagnosed with a life-limiting illness or they've had big changes where I think this is warranted, I think this conversation has to start.
• 20:28
  SPEAKER_00: So I really love that that Susan brought up that this is a conversation.
• 20:31
  SPEAKER_00: This is not a one-time decision.
• 20:33
  SPEAKER_00: Um, this is something that I think is should be ongoing ideally, and and something then there hopefully people will feel comfortable and informed and can, I think, will trust their providers and making these decisions.
• 20:46
  SPEAKER_00: We know that when people transition to hospice, that people are still, you know, using antibiotics curatively, even though they they've made this decision, they're still writing this prescription on discharge, hoping to cure this infection versus that they actually think it has symptomatic benefit.
• 20:59
  SPEAKER_00: And we published this in the journal American Geriatric Society.
• 21:02
  SPEAKER_00: Sarah Servid was the first author.
• 21:04
  SPEAKER_00: That was retrospective, but I I think it still gives some indication that people aren't really aligned with necessarily what what the goals of hospice there were likely uh would have been we weren't there for the patient conversation, but that these are you know in important considerations.
• 21:19
  SPEAKER_00: So I I think education is the biggest one and also being proactive and starting earlier because you never know when people are actually going to be able to engage in in this conversation.
• 21:28
  SPEAKER_00: And even if things change, the you know the context changes, then I think you revisit this.
• 21:32
  SPEAKER_00: This is something that is not, you know, should not be a one-time conversation.
• 21:35
  SPEAKER_02: Thank you so much.
• 21:36
  SPEAKER_02: I'd like to thank you both for a fantastic conversation.
• 21:39
  SPEAKER_02: We really appreciate you joining us today.
• 21:42
  SPEAKER_02: Yeah, it was great.
• 21:42
  SPEAKER_01: I enjoyed a good conversation for sure.
• 21:45
  SPEAKER_00: Same.
• 21:45
  SPEAKER_00: Thanks so much.
• 21:46
  SPEAKER_00: Appreciate it.
• 21:47
  SPEAKER_02: You can find more educational content like this podcast on Shay's online education center, learning CE, at www.learningce.shay dash online.org.
• 21:59
  SPEAKER_02: This concludes today's episode of the infection prevention and antibiotic stewardship end of life series.
• 22:04
  SPEAKER_02: Thank you for tuning in.