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Many doctors prescribe dying patients antimicrobials despite resistance concerns

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March 13, 2018

In a survey of physicians, about half said they felt the use of antimicrobials during end-of-life care contributes to antimicrobial resistance, according to researchers.

Nonetheless, for certain diseases, many physicians said they continue prescribing the medications for dying patients, the researchers wrote in Infection Control & Hospital Epidemiology. The reasons for continuing antimicrobial treatment varied according to disease and the imminence of death, among other factors.

“Many factors, including patient-centeredness, workplace culture and clinical considerations, contribute to the decision framework that physicians utilize when prescribing antimicrobials at the end of life,” researcher Christopher E. Gaw, MD, MBE, of the Children’s Hospital of Philadelphia (CHOP) division of general pediatrics, and colleagues wrote. “Adult and pediatric physicians approach antimicrobial use in their respective patient populations differently. Physicians may be overweighing the benefits of continuing antimicrobial therapy in patients at the end of life due to complex sociobehavioral factors.”

To gauge attitudes regarding end-of-life antimicrobial use, the researchers surveyed physicians and fellows at the University of Pennsylvania and CHOP. Those with the university were considered adult physicians, whereas those with CHOP were deemed pediatric physicians.

Participants indicated whether and how often they would administer antimicrobials for certain diseases and under certain circumstances. The researchers left the participants to define “end of life” for themselves. In all, 136 pediatric physicians and 147 adult physicians completed the survey.

Nearly all participants — 96.1% — agreed with the statement, “The overuse of antibiotics contributes to antibiotic resistance.” However, only 49.8% overall agreed with the statement, “Antimicrobial use in end-of-life care contributes to antibiotic resistance.” The researchers said that 60.5% of adult physicians agreed with the latter statement, compared with 38.2% of pediatric physicians. More than a third of participants overall — 38.2% — were neutral or uncertain of the effect of end-of-life antimicrobial use on resistance. In addition, 86.2% of participants said they believed it was important to respect a patient’s desire to continue antimicrobial use.

Adult and pediatric physicians continued to differ significantly in their willingness to administer antimicrobials according to disease and circumstance. For instance, 46.9% of adult physicians and 69.9% of pediatric physicians said they would continue antimicrobial treatment of pneumonia in end-of-life care. Similarly, 44.9% of adult physicians vs. 70.6% of pediatric physicians said they would treat central nervous system infections like meningitis and encephalitis in end-of-life care.

Adult physicians also differed significantly from pediatric physicians in their preference

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for continuing antimicrobials for stable patients enrolled in hospice (61.2% vs. 80.9%), the researchers said. For patients enrolled in hospice and for whom death was imminent, 2.7% of adult physicians and 19.9% of pediatric physicians said they would still use antimicrobials.

Based on answers to open-ended questions included in the survey, the researchers identified three general rationales behind continuing antimicrobial treatment in end-of-life care:

  • a desire to avoid the perception by patients’ family members that they were simply giving up;
  • uncertainty of whether the patient is actually nearing death; and
  • a desire to reduce the patient’s suffering.

Given these and other physician perspectives, Gaw and colleagues said common motivators for reducing antimicrobial use may not always be convincing for those rendering end-of-life care.

“Cost and population health benefits, which are common ethical justifications for antimicrobial stewardship, may not resonate with physicians caring for these patients,” they wrote. “Further research is needed to assess physician and patient attitudes and the factors that shape decision-making to better guide antimicrobial recommendations at the end of life.” – by Joe Green

Disclosures: The authors report no relevant financial disclosures.