10.11 Treatment failure and palliative care

When a treatment is failing, treatment outcome should be recorded as "treatment failure" (Chapter 17).

A new baseline specimen should be collected, and a new individualized regimen designed according to the principles described in Section 10.2.2.

When the minimum number of likely effective drugs cannot be reached, the use of TB drugs under development available for compassionate use is encouraged (Appendix 18).

When no therapeutic option or new regimen is possible, the patient can continue a TB regimen that is reasonably tolerated, or the regimen can be stopped. The decision to stop treatment should be made after careful evaluation and consultation with the patient, family, and TB treatment team. Palliative and supportive care should be continued.

Palliative and supportive care is an integral part of patient care throughout their illness [1] Citation 1. World Health Organization. Planning and implementing palliative care services: a guide for programme managers. Geneva. 2016.
https://apps.who.int/iris/bitstream/handle/10665/250584/9789241565417-eng.pdf?sequence=1&isAllowed=y [2] Citation 2. Hughes, J. Snyman, L. Palliative care for drug-resistant tuberculosis: when new drugs are not enough. The Lancet Respiratory Medicine. Volume 6, Issue 4, P251-252, April 01, 2018.
https://doi.org/10.1016/S2213-2600(18)30066-3 . Some care should be continued after cure if the patient remains with significant respiratory damage.

Palliative and supportive include [3] Citation 3. World Health Organization. Companion handbook to the WHO guidelines for the programmatic management of drug-resistant tuberculosis. Geneva. 2014.
https://www.ncbi.nlm.nih.gov/books/NBK247420/pdf/Bookshelf_NBK247420.pdf :

• Relief of respiratory symptoms: oxygen for shortness of breath; corticosteroids (prednisolone) for severe respiratory failure; codeine to help control cough.
• Identification, assessment and treatment of pain: non-opioids/mild opioids/strong opioids depending on the intensity of pain.
• Use of all necessary ancillary drugs.
• Nutritional support for undernourished patients.
• Care to improve comfort and prevent complications in debilitated patients; regular position changes in bedridden patients to prevent bedsores; bathing and oral hygiene to improve patient comfort and prevent skin infections
• Management of anxiety or depression (due to prolonged illness, separation from family, difficult living conditions, etc.); support to family as needed.

Offer home care to families who need help. Reserve inpatient rooms for end-of-life patients if they cannot be cared for at home.