Sepsis, the body’s self-destructive inflammatory response to severe infection, is the leading cause of death in U.S. hospitals, particularly among the elderly. It starts as mild sepsis, advances to severe sepsis, and all too frequently blossoms into septic shock. More than 1.5 million Americans get sepsis each year. More than 250,000 die of the illness. One in three patients who die in a hospital have sepsis. 62percent of survivors are re-hospitalized within 30 days. Over 90 percent of cases start in the community.
Understanding the critical role sepsis plays at the end of so many lives is important.
September is Sepsis Awareness Month. Organizations participating in Sepsis Awareness emphasize early diagnosis and treatment because of a large and important study reported in the New England Journal of Medicine during the spring of 2017.
It confirms what so many physicians have believed for so long. Time is of the essence when treating sepsis.
The study involved more than 110,000 patients in the state of New York and showed that when a checklist of care, required there by law since 2013, was completed within three hours, the risk of death was reduced. For every hour beyond three hours, the risk of death increased by four percent.
The New York regulations – known as Rory’s Regs – were inspired by the tragic death of a twelve-year-old boy, Rory Staunton, whose scraped elbow was overlooked while he was mistreated for a “stomach flu” rather than severe sepsis. The algorithm he inspired requires New York hospitals to have a high level of suspicion for sepsis with any potential infection; to do specific diagnostic tests; and, to administer powerful antibiotics with large volumes of intravenous fluid early in the course of the illness.
Further inspired by Rory’s death, the multiple organizations that promote sepsis awareness to the public educate patients about the myriad symptoms sepsis can cause. Their recommendation to the public is to be ready, on arrival at the emergency room, to ask the physician, “Could this be sepsis?” “If so, treat it early.”
But should there not be another educational emphasis? Should elderly patients (those patients over the age of 65 with an advanced chronic illness — such as cancer or heart failure — or any person over the age of 85) be educated as to the poor prognosis associated with the treatment of sepsis in their demographic?
Currently, sepsis kills almost 260,000 Americans per year, up from about 165,000 in the late 70s. The incidence of sepsis is increasing most dramatically in the older population. Patients over the age of 65 represent twelve percent of the U.S. population but almost 65 percent of sepsis cases. And while overall mortality from severe sepsis is improving incrementally, dropping to about 25 percent among young adults, it remains above 60 percent in the elderly.
Perhaps some of the increasing incidence of sepsis is explained by the increased awareness, but most of the increase is the result of an aging population, immunosuppression, and more drug-resistant bacteria.
The mainstay of therapy remains the early administration of antibiotics, high volumes of intravenous fluids, and a massive mobilization of medical technology. When the infection is severe, this treatment is likely to involve weeks of pain or discomfort in the intensive care unit (including mechanical ventilation, large bore IVs in the neck and groin, bladder catheters, drainage tubes in the chest and abdomen, hemodialysis, protective restraints, etc.) and will result in long-term complications for many survivors including permanent organ damage (heart, lung, and kidney failure), mental changes akin to post-traumatic stress disorder, and frequently, the loss of parts of extremities to amputations for gangrene.
I remember caring for a colleague’s patient, a healthy 85-year-old woman, who underwent a routine colonoscopy. Cautery of a small blood vessel resulted in a tiny perforation – too small to justify surgery. She was immediately started on antibiotics with the expectation of a quick recovery. Unfortunately, her aged immune system failed to respond appropriately. Over the next few days, she deteriorated into septic shock. Dramatic treatment saved her life; but after weeks in the ICU and the partial amputation of three limbs for gangrene, she was discharged to a nursing home with decreased kidney function, heart failure, and brain damage.
Parsing the New England Journal of Medicine study a bit further, one finds that of the 111,816 patients initially involved, only 3,853 declined treatment (in real time or by advance directive) despite the likelihood that more than 71,000 patients over the age of 65 were initially included. Of that aging cohort, a large percentage died despite painful treatment and most of the survivors have dramatically altered and foreshortened lives.
So, my question is why not discuss the option to decline treatment in the new patient education dynamic? Why not educate elderly patients and their families to tell the ER or ICU physicians that they want the diagnosis of sepsis to be considered but if the disease progresses and the diagnosis of septic shock is made, they want to decline further fluids, antibiotics, and life support. In their place, they want palliative care.
Although death from untreated sepsis is certain, most patients who decline treatment will have much less suffering. In my experience with elderly patients, painless confusion and disorientation are usually present when the septic patient is first seen. This altered mental status frequently evolves into a comparatively tolerable coma. With palliative medications, symptoms will be limited, and one will suffer much less than those who undergo aggressive treatment only to die later or to survive in a dramatically reduced state with ongoing complications.
Just as it is difficult to stop the cascade of septic complications, once in motion, it is difficult to stop the cascade of medical decisions that results in overly aggressive medical care. No reasonable person would have declined the initial antibiotics for the seemingly minor perforation I described a few paragraphs ago. That complication appeared eminently treatable. But if that elderly patient had educated her family to decline treatment for severe sepsis and had taken palliative treatment for the septic shock, she and her family would have been spared significant agonies and a prolonged death.
Early detection of sepsis is laudable. But making the diagnosis is not universally helpful until the prognosis is factored in. When a young person dies from sepsis it is a tragedy. When an elderly patient dies from sepsis, as so many inevitably do, it is a loss but not a tragedy. And if such a patient died while comforted by palliative care, without excessive and futile treatment, it might be considered a small mercy.
Samuel Harrington is a gastroenterologist and author of At Peace: Choosing a Good Death After a Long Life.
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