Hostname: page-component-586b7cd67f-rcrh6 Total loading time: 0 Render date: 2024-11-23T09:11:48.407Z Has data issue: false hasContentIssue false
  • English
  • Français

Physician Perceptions Regarding Antimicrobial Use in End-of-Life Care

Published online by Cambridge University Press:  12 February 2018

Christopher E. Gaw ,
Keith W. Hamilton ,
Jeffrey S. Gerber  and
Julia E. Szymczak
Christopher E. Gaw*
Affiliation:
Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
Keith W. Hamilton
Affiliation:
Division of Infectious Diseases, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
Jeffrey S. Gerber
Affiliation:
Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
Julia E. Szymczak
Affiliation:
Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
*
Address correspondence to Christopher E. Gaw, MD, MBE, Division of General Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 ([email protected]).
Get access Rights & Permissions [Opens in a new window]

Abstract

BACKGROUND

The decision to utilize antimicrobials in end-of-life situations is complex. Understanding the reasons why physicians prescribe antimicrobials in this patient population is important for informing the design of antimicrobial stewardship interventions.

METHODS

A 51-item survey containing both closed and open-ended questions on end-of-life antimicrobial use was administered to physicians affiliated with the University of Pennsylvania and Children’s Hospital of Philadelphia from January through April 2017. A mixed-methods approach was used to analyze responses.

RESULTS

Of 637 physicians surveyed, 283 responses (44.4%) were received. Most (86.2%) physicians believed that respecting a patient’s wish to continue antimicrobials was important. Approximately half of physicians (49.8%) believed that antimicrobial use at the end of life contributes to resistance. A higher proportion of pediatricians would often or always continue antimicrobial treatment for active infections and for hospice patients whose death was imminent compared to adult physicians (P<.001). Analysis of free-text responses revealed additional reasons why physicians may continue antimicrobials at end of life, including meeting family expectations, wanting to avoid the perception of “giving up,” uncertainty about prognosis, and reducing patient pain or discomfort.

CONCLUSIONS

Physician decision making concerning antimicrobial use in patients at the end of life is multifactorial. Clinicians may overweigh the benefits of antimicrobial therapy in end-of-life situations and view the importance of adhering to stewardship policies differently. Pediatric and adult clinicians have different approaches to this patient population. Better understanding of the complex decision making that occurs in the end-of-life patient population can help guide antimicrobial stewardship policies and improve patient care.

Infect Control Hosp Epidemiol 2018;39:383–390

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 39 , Issue 4 , April 2018 , pp. 383 - 390
Copyright
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1. Antibiotic resistance threats in the United States, 2013. Centers for Disease Control and Prevention website. https://www.cdc.gov/drugresistance/threat-report-2013/index.html. Published 2013. Accessed January 10, 2018.Google Scholar
2. Ford, PJ, Fraser, TG, Davis, MP, Kodish, E. Anti-infective therapy at end of life: ethical decision-making in hospice-eligible patients. Bioethics 2005;19:379–392.Google Scholar
3. Yeo, JM. Antimicrobial stewardship: improving antibiotic prescribing practice in a respiratory ward. BMJ Qual Improv Rept 2016;5(1):u206491–w3570.Google Scholar
4. Gilchrist, M, Wade, P, Ashiru-Oredope, D, et al. Antimicrobial stewardship from policy to practice: experiences from UK antimicrobial pharmacists. Infect Dis Ther 2015;4(Suppl 1):51–64.Google Scholar
5. Hersh, AL, De Lurgio, SA, Thurm, C, et al. Antimicrobial stewardship programs in freestanding children’s hospitals. Pediatrics 2015;135:33–39.Google Scholar
6. Drekonja, DM, Filice, GA, Greer, N, et al. Antimicrobial stewardship in outpatient settings: a systematic review. Infect Control Hosp Epidemiol 2015;36:142–152.Google Scholar
7. Fishman, N. Antimicrobial stewardship. Am J Infect Control 2006;34:S55–S63.Google Scholar
8. Davey, P, Marwick, CA, Scott, CL, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017;2:CD003543.Google Scholar
9. Thompson, AJ, Silveira, MJ, Vitale, CA, Malani, PN. Antimicrobial use at the end of life among hospitalized patients with advanced cancer. Am J Hosp Palliat Care 2012;29:599–603.Google Scholar
10. Vitetta, L, Kenner, D, Sali, A. Bacterial infections in terminally ill hospice patients. J Pain Symptom Manage 2000;20:326–334.Google Scholar
11. Hamilton, KW, Fishman, NO. Antimicrobial stewardship interventions: thinking inside and outside the box. Infect Dis Clin North Am 2014;28:301–313.Google Scholar
12. D’Agata, E, Mitchell, S. Patterns of antimicrobial use among nursing home residents with advanced dementia. Arch Intern Med 2008;168:357–362.Google Scholar
13. Chun, ED, Rodgers, PE, Vitale, CA, Collins, CD, Malani, PN. Antimicrobial use among patients receiving palliative care consultation. Am J Hosp Palliat Care 2010;27:261–265.Google Scholar
14. Furuno, JP, Noble, BN, Horne, KN, et al. Frequency of outpatient antibiotic prescription on discharge to hospice care. Antimicrob Agents Chemother 2014;58:5473–5477.Google Scholar
15. Reinbolt, RE, Shenk, AM, White, PH, Navari, RM. Symptomatic treatment of infections in patients with advanced cancer receiving hospice care. J Pain Symptom Manage 2005;30:175–182.Google Scholar
16. Albrecht, JS, McGregor, JC, Fromme, EK, Bearden, DT, Furuno, JP. A nationwide analysis of antibiotic use in hospice care in the final week of life. J Pain Symptom Manage 2013;46:483–490.CrossRefGoogle ScholarPubMed
17. Metlay, JP, Shea, JA, Crossette, LB, Asch, DA. Tensions in antibiotic prescribing: pitting social concerns against the interests of individual patients. J Gen Intern Med 2002;17:87–94.Google Scholar
18. Marcus, EL, Clarfield, AM, Moses, AE. Ethical issues relating to the use of antimicrobial therapy in older adults. Clin Infect Dis 2001;33:1697–1705.Google Scholar
19. Leibovici, L, Paul, M. Ethical dilemmas in antibiotic treatment: focus on the elderly. Clin Microbiol Infect 2015;21:27–29.Google Scholar
20. Leibovici, L, Paul, M, Ezra, O. Ethical dilemmas in antibiotic treatment. J Antimicrob Chemother 2012;67:12–16.Google Scholar
21. Harris, PA, Taylor, R, Thielke, R, Payne, J, Gonzalez, N, Conde, JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–381.Google Scholar
22. Huberman, AM, Miles, MB. Qualitative Data Analysis: An Expanded Sourcebook. 2nd ed. Thousand Oaks, CA: SAGE; 1994.Google Scholar
23. Buss, MK, Rock, LK, McCarthy, EP. Understanding palliative care and hospice: a review for primary care providers. Mayo Clin Proc 2017;92:280–286.Google Scholar
24. Rodríguez-Prat, A, Monforte-Royo, C, Porta-Sales, J, Escribano, X, Balaguer, A. Patient perspectives of dignity, autonomy and control at the end of life: systematic review and meta-ethnography. PLoS One 2016;11(3):e0151435.Google Scholar
25. Rosenberg, JH, Albrecht, JS, Fromme, EK, et al. Antimicrobial use for symptom management in patients receiving hospice and palliative care: a systematic review. J Palliat Med 2013;16:1568–1574.Google Scholar
26. Kalil, AC, Metersky, ML, Klompas, M, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016;63(5):e61–e111.Google Scholar
27. Barry, MJ, Edgman-Levitan, S. Shared decision making—the pinnacle of patient-centered care. N Engl J Med 2012;366:780–781.Google Scholar
28. AAP Committee on Hospital Care. Family-centered care and the pediatrician’s role. Pediatrics 2003;112:691–696.Google Scholar
29. McCaffrey, N, Bradley, S, Ratcliffe, J, Currow, DC. What aspects of quality of life are important from palliative care patients’ perspectives? A systematic review of qualitative research. J Pain Symptom Manage 2016;52:318–328.Google Scholar
30. Bakitas, M, Lyons, KD, Hegel, MT, Ahles, T. Oncologists’ perspectives on concurrent palliative care in an NCI-designated comprehensive cancer center. Palliat Support Care 2013;11:415–423.Google Scholar
31. Snow, CE, Varela, BR, Pardi, DA, Adelman, RD, Said, S, Reid, MC. Identifying factors affecting utilization of an inpatient palliative care service: a physician survey. J Palliat Med 2009;12:231–237.Google Scholar
32. Garau, J. Impact of antibiotic restrictions: the ethical perspective. Clin Microbiol Infect 2006;12(Suppl 5):16–24.Google Scholar
33. Charani, E, Castro-Sánchez, E, Holmes, A. The role of behavior change in antimicrobial stewardship. Infect Dis Clin North Am 2014;28:169–175.Google Scholar
34. Charani, E, Castro-Sanchez, E, Sevdalis, N, et al. Understanding the determinants of antimicrobial prescribing within hospitals: the role of “prescribing etiquette. Clin Infect Dis 2013;57:188–196.Google Scholar
35. Skodvin, B, Aase, K, Charani, E, Holmes, A, Smith, I. An antimicrobial stewardship program initiative: a qualitative study on prescribing practices among hospital doctors. Antimicrob Resist Infect Control 2015;4:24.Google Scholar
36. Jin, J. Clinicians examine advances and challenges in improving quality of end-of-life care in the ICU. JAMA 2013;310:2493–2495.Google Scholar
37. Larochelle, MR, Rodriguez, KL, Arnold, RM, Barnato, AE. Hospital staff attributions of the causes of physician variation in end-of-life treatment intensity. Palliat Med 2009;23:460–470.Google Scholar
38. Baumrucker, S, Stolick, M, Oertli, KA, et al. Aggressive treatment at end of life. Am J Hosp Palliat Med 2016;33:703–709.Google Scholar
39. Bachmann, LM, Mühleisen, A, Bock, A, ter Reit, G, Held, U, Kessels, AG. Vignette studies of medical choice and judgement to study caregivers’ medical decision behaviour: systematic review. BMC Med Res Methodol 2008;8(50): doi: 10.1186/1471-2288-8-50. Google Scholar
Supplementary material: PDF

Gaw et al. supplementary material 1

Gaw et al. supplementary material

Download Gaw et al. supplementary material 1(PDF)
PDF 155.8 KB
Supplementary material: File

Gaw et al. supplementary material 2

Gaw et al. supplementary material

Download Gaw et al. supplementary material 2(File)
File 105.8 KB