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Antibiotics
in End of Life Care raises concerns
Newswise — Antibiotics appear to be
frequently prescribed to individuals with
advanced dementia in nursing homes,
especially in the two weeks before death,
according to a report in the February 25
issue of Archives of Internal Medicine, one
of the JAMA/Archives journals.
More than 5 million Americans have dementia,
according to background information in the
article.
About 70 percent of them will live in
nursing homes at the end of their lives.
Recurrent infections and fever are common
among these patients, who may receive
antibiotics to treat these conditions.
Erika D’Agata, M.D., M.P.H., of Beth Israel
Deaconess Medical Center, Harvard Medical
School, Boston, and colleagues studied 214
residents (average age 85.2) with advanced
dementia living in 21 area nursing homes.
The participants underwent an initial
assessment between 2003 and 2006 and then
were examined every three months for a
maximum of 18 months.
At
each evaluation, the number of courses of
antibiotic therapy prescribed since the
prior visit was obtained from facility
records.
During an average of 322 days of follow-up,
142 (66.4 percent) participants received at
least one course of antibiotics and the
overall average was four courses. Of the 99
(46.3 percent) residents who died, 42 (42.4
percent) received antibiotics during the two
weeks before their death.
“The proportion of residents taking
antimicrobials was seven times greater in
the last two weeks of life compared with six
to eight weeks before death,” the authors
write.
Thirty of the 72 courses (41.7 percent) in
the last two weeks of life were administered
intravenously rather than by mouth, a method
that may be uncomfortable for patients with
advanced dementia.
“This extensive use of antimicrobials and
pattern of antimicrobial management in
advanced dementia raises concerns not only
with respect to individual treatment burden
near the end of life but also with respect
to the development and spread of
antimicrobial resistance in the nursing home
setting,” the authors write.
The results support “the development of
programs and guidelines designed to reduce
the use of antimicrobial agents in advanced
dementia.”
Editor’s Note:
This study was supported by a grant from the
National Institute on Aging, National
Institutes of Health. Please see the article
for additional information, including other
authors, author contributions and
affiliations, financial disclosures, funding
and support, etc.
Editorial: Antibiotics
Raise Ethical Dilemmas That Must Be Solved
Individually
“The findings in this study require the
medical community to ask whether the
extensive use of antibiotics in this
particular patient population is
appropriate, taking two factors into
consideration: the benefit to the patient
treated and the risk imposed on other
patients,” write Mitchell J. Schwaber, M.D.,
M.Sc., and Yehuda Carmeli, M.D., M.P.H., of
the Tel Aviv Medical Center, Israel, in an
accompanying editorial.
“The solution is not to categorically deny
antibiotics to the severely demented
elderly, or even to impose limits on their
use or their spectrum as a matter of
policy,” they continue.
“We must, however, begin to consider every
decision to use antibiotics in this
population as we would decisions regarding
other treatment modalities, including
resuscitation and major surgery.
"That
is, we must ask whether the interests of the
patient are being served by using
antibiotics. We must further ask whether the
use of antibiotics in each specific patient
justifies the risk placed on others by their
use.”
“All such decisions must ultimately be made
individually, based on the medical situation
and the expressed wishes of the patient and
family, as well as on the physician’s
judgment of the benefits and risks entailed
in treating vs. not treating,” they
conclude.
(Arch Intern Med. 2008;168[4]:349-350.
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