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Kang M, Wang WS, Chang Z. Antibiotic Use at the End of Life: Current Practice and Ways to Optimize. Am J Hosp Palliat Care 2024:10499091241266986. [PMID: 39030663 DOI: 10.1177/10499091241266986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2024] Open
Abstract
Infections are common complications in end of life (EOL). However, clinicians have minimal guidance regarding antibiotic decision-making in EOL care, leading to the overuse of antibiotics. While symptom relief is frequently cited as a major reason for antibiotic use in EOL, antibiotics have not been shown to provide significant improvement in symptoms outside of urinary tract infections. In addition, when prognosis is expected to be in the range of days to weeks, antibiotics have not been shown to provide significant survival benefit. Antibiotics can be beneficial in EOL care in appropriate scenarios, but the current widespread use of antibiotics in EOL requires reevaluation. There needs to be broader efforts to think about antibiotics like other invasive medical procedures in which benefits and risks are weighed, recognizing that not all patients in EOL who receive antibiotics will benefit. In addition, during care planning process, discussing and documenting antibiotic preferences will be beneficial. Non-antibiotic symptom management should be incorporated to plan of care when infection is suspected. Ultimately, the use of antibiotics at EOL should be for the clear benefit for the recipient and should be guided by the type of infection and its clinical course, patients' primary disease and its prognosis, and the preferences of patients or surrogate decision makers.
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Affiliation(s)
- Minji Kang
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Winnie S Wang
- Division of General Internal Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Zieanna Chang
- Division of General Internal Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
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Sánchez-Cárdenas MA, Vargas-Escobar LM, Correa-Morales JE, Michelsen-Andrade M, González-Salazar L, Muñoz-Olivar C, López Alba JA, León-Delgado MX. Effectiveness of Subcutaneous Administration of Antibiotics to Control Infections in Elder Palliative Patients: A Systematic Review. Am J Hosp Palliat Care 2023; 40:1379-1389. [PMID: 36964691 DOI: 10.1177/10499091231156866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023] Open
Abstract
Background: Infections are common in patients with advanced illnesses for whom the intravenous or oral route is not possible. The subcutaneous administration of antibiotics is a promising alternative, but there is not enough theoretical support for its use. This study aims to explore the effectiveness and safety of subcutaneous antibiotic therapy in the context of palliative care in elderly patients. Methods: A systematic review was conducted using PubMed and Embase, without time or language limits. Seven articles were selected on the effectiveness of subcutaneous antibiotic therapy in adult patients with chronic progressive diseases. The quality of the articles was assessed with the Newcastle Ottawa Scale and relevant data was extracted using a selection capture file. Results: Seven quasi-experimental studies evaluated 865 elderly patients with advanced diseases, comorbidities, and infections (ie, urinary tract, respiratory system, and bone joint) who received subcutaneous antibiotic therapy (ie, Ceftriaxone, Ertapenem, and Teicoplanin). The pooled success rate of subcutaneous antibiotics for the 7 studies was 71%, the therapy failure rate was 22%, its withdrawal mean was 8%, and the mean mortality rate was 7%. The studies were of low quality and were heterogeneous in the types of infections, types of antibiotics, time of follow-up, and outcomes assessed. Conclusions: Pilot studies have found a limited number of antibiotics that can be safely used to treat specific infections. Nevertheless, the data isn´t robust enough to recommend their use.
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Larnard J, Stead W, Branch-Elliman W. Considering Patient, Family, and Provider Goals and Expectations in a Rapidly Changing Clinical Context: A Framework for Antimicrobial Stewardship at the End of Life. Infect Dis Clin North Am 2023; 37:139-151. [PMID: 36805010 DOI: 10.1016/j.idc.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Antibiotic administration is often a part of end-of-life (EOL) care, including among patients who are not critically ill. Guideline-issuing bodies recommend that antimicrobial stewardship providers (ASPs) provide support to prescribers making decisions about whether or not to treat infections in this population. Relatively little is known about the rationale for antimicrobial prescribing during the EOL period in noncritical care settings, although patient and family preferences are often an influencing factor. The effectiveness of antimicrobials in improving quantity or quality of life in this population is unclear and likely context-specific.
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Affiliation(s)
- Jeffrey Larnard
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Suite GB, Boston, MA 02215, USA.
| | - Wendy Stead
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Suite GB, Boston, MA 02215, USA
| | - Westyn Branch-Elliman
- Department of Medicine, Section of Infectious Diseases, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132, USA; Department of Medicine, Harvard Medical School
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4
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Mamak T, Hadiseh H, Shirin F, Masoud P, Mohammadreza S, Mahsa A. Antibiotic Treatment in End Stage Cancer Patients; Advantages and Disadvantages. Cancer Inform 2023; 22:11769351231161476. [PMID: 37008074 PMCID: PMC10064464 DOI: 10.1177/11769351231161476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/16/2023] [Indexed: 03/31/2023] Open
Abstract
Aim: In this study our aim was to elucidate whether advanced cancer patients benefit from antibiotic treatment in the last days of life in addition to reviewing the relevant costs and effects. Materials And Methods: We reviewed medical records from 100 end-stage cancer patients and their antibiotic use during the hospitalization in Imam Khomeini hospital. Patient’s medical records were analyzed retrospectively for cause and periodicity of infections, fever, increase in acute phase proteins, cultures, type and cost of antibiotic. Results: Microorganisms were found in only 29 patients (29%) and the most microorganism among the patients was E. coli (6%). About 78% of the patients had clinical symptoms. The highest dose of antibiotics was related to Ceftriaxone (40.2%) and in the second place was Metronidazole (34.7%) and the lowest dose was related to Levofloxacin, Gentamycin and Colistin (1.4%). Fifty-one patients (71%) did not have any side effects due to antibiotics. The most common side effect of antibiotics among patients was skin rash (12.5%). The average estimated cost for antibiotic use was 7 935 540 Rials (24.4 dollars). Conclusion: Prescription of antibiotics was not effective in symptom control in advanced cancer patients. The cost of using antibiotics during hospitalization is very high and also the risk of developing resistant pathogens during admission should be considered. Antibiotic side effects also occur in patients, causing more harm to the patient at the end of life. Therefore, the benefits of antibiotic advice in this time is less than its negative effects.
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Affiliation(s)
- Tahmasebi Mamak
- Cancer Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hosamirudsari Hadiseh
- Department of Infectious Diseases, Baharloo Hospital, Railway Square, Tehran University of Medical Sciences, Tehran, Iran
- Hosamirudsari Hadiseh, Department of Infectious Diseases, Baharloo Hospital, Railway Square, Tehran University of Medical Sciences, Enqelab street, Tehran, 1416753955, Iran.
| | | | - Parash Masoud
- Department of Infectious Diseases, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Salehi Mohammadreza
- Department of Infectious Diseases, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbaszadeh Mahsa
- Department of Internal Medicine, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Henri B, Sirvain S, de Wazieres B, Bernard L, Gavazzi G, Forestier E, Fraisse T. [Survey on antibiotic prescription practices for palliative care terminally ill patients of 75 years old and more]. Rev Med Interne 2022; 43:589-595. [PMID: 36064626 DOI: 10.1016/j.revmed.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/25/2022] [Accepted: 08/24/2022] [Indexed: 11/20/2022]
Abstract
Infections commonly occur terminally ill oldest patients in palliative care and questioned about antimicrobial use. The aim of this study was to describe practitioners' habits. METHOD ancillary study on antibiotic modalities according to the setting of care from a national practices survey based on self administered questionnaire sent by e-mail in 2017. RESULTS 220 practitioners/327 used antibiotic, 136 worked in hospital department (52 geriatricians), 20 nursing home and 64 general practitioners (GP). GP declared less palliative care patients (6/year). The antibiotic goal was symptomatic relief for 181 (82.3%) without statistically significant difference between groups. GP (25%) were the group that most collected patient opinion for antibiotic prescription. Nursing home (23%) and GP (18%) reported more urinary tract symptoms than others (11.7%) (P=0.003). Geriatricians (59.6%) declared significantly less urinary analysis than GP (90%) (P=0.0009). 212 doctor (96.4%) faced side effect (SI): more allergic reaction and less administration difficulties than the other groups. The stop decision was collegially took (156, 70,9%) significantly more in hospital (121, 89%) than in community (25, 39.1%) (P<0.001). Patient wishes were noted by 30 (46.96%) only GP. CONCLUSION Even if practice and number of patients follow up differ from each place of care, doctors' intention in antibiotic use respect palliative care goal to relieve discomfort. It is hard to diagnose infection and complementary exam are scarce. A repeated individualized evaluation with patient, his surrounding and his medical referent participation, is mandatory to give a constant adapted level of care in every place of care.
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Affiliation(s)
- B Henri
- Post-urgences gériatriques, CHU Purpan, 31000 Toulouse, France
| | - S Sirvain
- Court séjour gériatrique, CH Alès-Cevennes, 811 avenue du Dr J goubert, 30100 Ales, France
| | - B de Wazieres
- Service de gériatrie, CHU Caremeau, 30000 Nimes, France
| | - L Bernard
- Service de Maladies Infectieuses, CHU Hôpitaux de Tours, 37000 Tours, France
| | - G Gavazzi
- Service Universitaire de Gériatrie Clinique, CHU de Grenoble, 38000 Grenoble, France
| | - E Forestier
- Service de maladies infectieuses, Centre Hospitalier Métropole Savoie, 73000 Chambéry, France
| | - T Fraisse
- Court séjour gériatrique, CH Alès-Cevennes, 811 avenue du Dr J goubert, 30100 Ales, France.
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Sganga F, Salerno A, Borghetti A, Fantoni M, Turriziani A, Barillaro C, Bernabei R. Infections in hospitalised patients affected by end-stage diseases: a narrative overview. Int J Palliat Nurs 2022; 28:150-156. [PMID: 35465703 DOI: 10.12968/ijpn.2022.28.4.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM To analyse the presence and treatment of infections in hospitalised terminal patients by identifying potential risk factors. METHODS We conducted a retrospective study using health data from 229 terminally ill patients (evaluated by our hospital palliative care team (HPCT) hospitalised from January to December 2018. RESULTS A total of two types of infections were identified: blood flow infection (through blood cultures) and pneumonia (through radiological examinations), while the other cases of infection remained unknown. The most frequently identified microorganism was Staphylococcus spp. The prevalence of infections was higher in patients with non-oncological diseases (n=47, 36.7%; p value 0.009). The potential risk factors identified for infections were the presence of: Parkinson's disease (n=15, 11.7%; p value 0.005), dysphagia (n=49, 38.3%; p value 0.007), bedding (n=15, 11.7%; p value 0.048), pressure ulcers (n=31, 24. 2%); p value 0.018), oxygen therapy (n=60, 46.9%; p value 0.050), urinary catheters (n=95, 74.2%; p value 0.038) and polypathology (2.3 vs 1.7; p value 0.022). Parkinson's disease (OR=5.973; 95% CI=1.292-27.608), dysphagia (OR=2.090; 95% CI=1.080-4.046) and polypathology (OR=1.220; 95% CI=1.015-1.466) were confirmed by a corrected logistic regression analysis. CONCLUSIONS Infections and, consequently, antibiotic therapies, have a high prevalence in hospitalised patients with terminal disease. Potential risk factors for infections in these patients could be polypathology, dysphagia and Parkinson's disease. Patients with these conditions could benefit from prevention programmes.
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Affiliation(s)
- Federica Sganga
- Doctor, UOSA Palliative Care, University Hospital Foundation; Geriatric and Orthogeriatric Unit, S. Anna University Hospital Italy
| | | | - Alberto Borghetti
- Doctor, UOC Infectious Diseases, University Hospital Foundation, Italy
| | - Massimo Fantoni
- Professor, Sacred Heart Catholic University; UOC Infectious Diseases, University Hospital Foundation, Italy
| | | | | | - Roberto Bernabei
- Professor, UOSA Palliative Care, University Hospital Foundation; Sacred Heart Catholic University, Italy
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Odagiri T, Maeda I, Masanori Mori, Morita T, Kaneishi K, Junko Nozato, Kazuhiro Kosugi, Higashibata T, Hamano J, Shimoinaba J, Nishi T, Kawashima N. Title: Effects of Antibiotics on Respiratory Symptoms in Terminally Ill Cancer Patients With Pneumonia: A Multicenter Cohort Study. Am J Hosp Palliat Care 2022; 39:1082-1089. [PMID: 35341338 DOI: 10.1177/10499091211058156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
CONTEXT Patients in the terminal stages of cancer are frequently affected by infection, especially pneumonia; but the effects of antibiotics on respiratory symptoms and factors associated with improvement are still unclear. OBJECTIVES This study aimed to clarify the effects of antibiotics on respiratory symptoms of terminally ill cancer patients with pneumonia, and to explore factors associated with the improvement. METHODS This was a prospective cohort study in which we consecutively recruited terminally ill cancer patients diagnosed with pneumonia and treated with antibiotics at one of 23 palliative care units across Japan. At the baseline and Day 3, primarily responsible palliative care specialists recorded patient backgrounds, the results of physical and laboratory examination, and patient symptoms using the Support Team Assessment Schedule. Improvement was defined as improvement of dyspnea, cough, and sputum production on Day 3. RESULTS Among all 1896 patients admitted during the study periods, 137 patients (7.2%) were enrolled into this study. Improvement was achieved in 65 patients (47.4%; 95% confidence intervals, 39-56). Univariate analyses revealed that the Palliative Prognostic Index (PPI), respiratory rate (RR), and oxygen requirement were significantly associated with the improvement. A multiple logistic regression analysis identified that PPI score of ≤ 6 and RR of <20 were independently associated with the improvement (odds ratios, 4.4 [1.6-12] and 2.5 [1.1-5.5], respectively). CONCLUSION Antibiotics may relieve respiratory symptoms from pneumonia in approximately half of the terminally ill cancer patients. PPI and respiratory rate are useful to identify the patients who received benefits of antibiotics.
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Affiliation(s)
- Takuya Odagiri
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
| | - Isseki Maeda
- Department of Palliative Care, Senri-chuo Hospital, Osaka, Japan
| | - Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Seirei Mikatahara Genral Hospital, Hamamatsu, Japan
| | - Keisuke Kaneishi
- Department of Palliative Internal Medicine, JCHO Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Junko Nozato
- Department of Internal Medicine, Palliative Care, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuhiro Kosugi
- Department of Palliative Medicine, 26351National Cancer Center Hospital East, Kashiwa, Japan
| | - Takahiro Higashibata
- Palliative Care Team, Department of General Medicine and Primary Care, 68320University of Tsukuba Hospital, Tsukuba, Japan
| | - Jun Hamano
- Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | | | - Tomohiro Nishi
- Kawasaki Municipal Ida Hospital, Kawasaki Comprehensive Care Center, Kawasaki, Japan
| | - Natsuki Kawashima
- Department of Palliative Medicine, 26420Tsukuba Medical Center Hospital, Tsukuba, Japan
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8
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C. Shekhar A. The Use of Antibiotics in Hospice and Palliative Care Settings. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2022; 25:50-54. [PMID: 37674891 PMCID: PMC10180008 DOI: 10.14475/jhpc.2022.25.1.50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/27/2022] [Accepted: 02/09/2022] [Indexed: 09/08/2023]
Abstract
Antibiotics are commonly prescribed medications in the hospice and palliative care setting, as well as in many other healthcare settings. The overuse or negligent use of antibiotics is associated with the harmful consequence of fostering the development of antibiotic-resistant pathogens. Thus, there is an urgent need to critically examine and audit antibiotic use in all aspects of healthcare. In the status quo, there is a lack of consistent standards and guidelines surrounding the use of antibiotics in hospice and palliative care settings, leading to significant variations in how antibiotics are prescribed and administered in end-of-life care. It is apparent that greater thought needs to go into antibiotic decisions for patients receiving hospice or palliative care, especially considering the harmful consequences of the overprescription of antibiotics. The literature suggests that many clinicians prescribe antibiotics inappropriately for patients who would not benefit from their use or prescribe them without adequate documentation. Clinicians should be deliberate about when they prescribe antibiotics and adhere to the appropriate documentation standards and procedures within their institution or community. Future research should seek to generate generalizable knowledge about which patients will benefit most from antibiotic therapy during end-of-life care.
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Affiliation(s)
- Aditya C. Shekhar
- Center for Bioethics, Harvard Medical School, Boston, MA, USA
- The University of Minnesota - Twin Cities, Minneapolis, MN, USA
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9
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AKDOĞAN D. Surveillance analysis and microbiological profiles of nosocomial infections in a palliative care center. KONURALP TIP DERGISI 2021. [DOI: 10.18521/ktd.986150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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10
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Clark MD, Halford Z, Herndon C, Middendorf E. Evaluation of Antibiotic Initiation Tools in End-of-Life Care. Am J Hosp Palliat Care 2021; 39:274-281. [PMID: 34169763 DOI: 10.1177/10499091211027806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Hospice patients are frequently confronted with potentially infectious complications necessitating antibiotic consideration. Information regarding the appropriate use of antibiotics and their impact on symptom management in hospice patients are unknown. OBJECTIVES This study aimed to evaluate and describe the use of an antibiotic initiation tool in patients admitted to outpatient hospice services. The primary outcome assessed the percentage of antibiotics that were appropriately initiated based on Loeb's Minimum Criteria (LMC) for Antibiotic Initiation Tool. Secondary outcomes included the number of patients with documented symptom resolution following antibiotic completion, the number of antibiotic courses that were successfully completed, and treatment-related adverse events. METHODS This was a retrospective, multisite, descriptive analysis of hospice patients treated with antibiotics between April 2019 and September 2020. RESULTS Two hundred and thirty patients were assessed for inclusion, with 172 meeting eligibility criteria and receiving a total of 201 antibiotic courses. Based on LMC, 84 of the 201 (42%) antibiotics ordered were appropriate, with 60% of these LMC-approved courses resulting in symptom resolution. Out of 201 total courses, 99 (49%) resulted in symptom resolution. Overall, 160 (80%) antibiotic courses were successfully completed. CONCLUSION In this study, antibiotic initiation in hospice patients frequently did not meet LMC. Less than half of the antibiotics prescribed led to symptom resolution despite antibiotic course completion in most patients. There is no consensus or guidelines directing appropriate antibiotic decision-making in hospice patients. The appropriate use of antibiotics in terminally ill patients warrants additional research.
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Affiliation(s)
- Matthew D Clark
- Pharmacy Clinical Programs, 4002The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zachery Halford
- Department of Pharmacy Practice, 4107Union University College of Pharmacy, Jackson, TN, USA
| | - Chris Herndon
- Department of Pharmacy Practice, 33140Southern Illinois University Edwardsville School of Pharmacy, Edwardsville, IL, USA.,Department of Community and Family Medicine, St. Louis School of Medicine, Edwardsville, IL, USA
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Fairweather J, Cooper L, Sneddon J, Seaton RA. Antimicrobial use at the end of life: a scoping review. BMJ Support Palliat Care 2020:bmjspcare-2020-002558. [PMID: 33257407 DOI: 10.1136/bmjspcare-2020-002558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To examine antibiotic use in patients approaching end of life, in terms of frequency of prescription, aim of treatment, beneficial and adverse effects and contribution to the development of antimicrobial resistance. DESIGN Scoping review DATA SOURCES: An information scientist searched Ovid MEDLINE, Ovid EMBASE, The Cochrane library, PubMed Clinical Queries, NHS Evidence, Epistemonikos, SIGN, NICE, Google Scholar from inception to February 2019 for any study design including, but not limited to, randomised clinical trials, prospective interventional or observational studies, retrospective studies and qualitative studies. The search of Ovid MEDLINE was updated on the 10 June 2020. STUDY SELECTION Studies reporting antibiotic use in patients approaching end of life in any setting and clinicians' attitudes and behaviour in relation to antibiotic prescribing in this population DATA EXTRACTION: Two reviewers screened studies for eligibility; two reviewers extracted data from included studies. Data were analysed to describe antibiotic prescribing patterns across different patient populations, the benefits and adverse effects (for individual patients and wider society), the rationale for decision making and clinicians behaviours and attitudes to treatment with antibiotics in this patient group. RESULTS Eighty-eight studies were included. Definition of the end of life is highly variable as is use of antibiotics in patients approaching end of life. Prescribing decisions are influenced by patient age, primary diagnosis, care setting and therapy goals, although patients' preferences are not always documented or adhered to. Urinary and lower respiratory tract infections are the most commonly reported indications with outcomes in terms of symptom control and survival variably reported. Small numbers of studies reported on adverse events and antimicrobial resistance. Clinicians sometimes feel uncomfortable discussing antibiotic treatment at end of life and would benefit from guidelines to direct care. CONCLUSIONS Use of antibiotics in patients approaching the end of life is common although there is significant variation in practice. There are a myriad of intertwined biological, ethical, social, medicolegal and clinical issues associated with the topic.
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Affiliation(s)
| | - Lesley Cooper
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland Glasgow, Glasgow, UK
| | - Jacqueline Sneddon
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland Glasgow, Glasgow, UK
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12
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Antibiotic use during end-of-life care: A systematic literature review and meta-analysis. Infect Control Hosp Epidemiol 2020; 42:523-529. [PMID: 33172507 DOI: 10.1017/ice.2020.1241] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND We performed a systematic literature review and meta-analysis measuring the burden of antibiotic use during end-of-life (EOL) care. METHODS We searched PubMed, CINAHL (EBSCO platform), and Embase (Elsevier platform), through July 2019 for studies with the following inclusion criteria in the initial analysis: antibiotic use in the EOL care patients (advanced dementia, cancer, organ failure, frailty or multi-morbidity). If the number of patients in palliative care consultation (PCC) was available, antibiotic use data were pooled to compare the proportion of patients who received antibiotics under PCC compared to those not receiving PCC. Random-effect models were used to obtain pooled mean differences, and heterogeneity was assessed using the I2 value. RESULTS Overall, 72 studies met the inclusion criteria and were included in the final review: 22 EOL studies included only patients with cancer; 17 studies included only patients with advanced dementia; and 33 studies included "mixed populations" of EOL patients. Although few studies reported antibiotic using standard metrics (eg, days of therapy), 48 of 72 studies (66.7%) reported antibiotic use in >50% of all patients. When the 3 studies that evaluated antibiotic use in PCC were pooled together, patients under PCC was more likely to receive antibiotics compared to patients not under PCC (pooled odds ratio, 1.73; 95% CI, 1.02-2.93). CONCLUSIONS Future studies are needed to evaluate the benefits and harms of using antibiotics for patients during EOL care in diverse patient populations.
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Durand M, Forestier E, Gras Aygon C, Sirvain S, de Wazières B, Bernard L, Paccalin M, Legout L, Roubaud Baudron C, Gavazzi G, Fraisse T. Determinants of doctors' antibiotic prescriptions for patients over 75 years old in the terminal stage of palliative care. Infect Dis Now 2020; 51:340-345. [PMID: 33075403 DOI: 10.1016/j.medmal.2020.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 03/31/2020] [Accepted: 10/12/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Notwithstanding high prevalence of presumably bacterial infections in elderly persons (EP) in palliative care (PC), there exists no recommendation on the role of antibiotic therapy (ABP) in this type of situation. OBJECTIVE To describe the determinants of antibiotic prescription by general practitioners (GP) and by doctors practicing in institutions (DPI) for patients>75 years, in end-of-life situations in PC. METHOD Descriptive investigation by anonymous self-administered questionnaire disseminated in France by e-mail. RESULTS A total of 301 questionnaires analyzed: 113 GP, 188 DPIs. The latter were mainly geriatricians (69, 36.6%) and infectologists/internists (41, 21.8%). Sixty-three (55,75%) GPs and 144 (78.7%) DPIs stated that they had prescribed antibiotics. Practice in "EHPAD" retirement homes or intensive care was often associated with non-prescription of antibiotics. Age, PC training and number of patients monitored bore no influence. Family involvement in decision-making was more frequent for GPs than for DPIs. The main purpose of antibiotic therapy was to relieve different symptoms (fever, respiratory congestion, functional urinary signs). Most of the doctors (81%) had previously encountered complications (allergy, adverse effect), which represented the main causes of treatment discontinuation. CONCLUSION Antibiotic use in end-of-life EPs in PC seems frequent. In accordance with the principle of beneficence, its goal of often symptom-related; that said, in the absence of scientific data, antibiotic prescription in end-of-life situations should be individualized in view of observing the other ethical caregiving principles (beneficence, non-maleficence, justice, patient autonomy) and re-evaluated daily.
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Affiliation(s)
- M Durand
- Court séjour gériatrique, CH Alès Cévennes, Avenue du Docteur Jean Goubert, 30100 Alès, France
| | - E Forestier
- Service de maladies infectieuses, Centre Hospitalier Métropole Savoie, 73000 Chambéry, France
| | - C Gras Aygon
- Département de médecine générale, UFR médecine Montpellier-Nîmes, 34000 Montpellier, France
| | - S Sirvain
- Court séjour gériatrique, CH Alès Cévennes, Avenue du Docteur Jean Goubert, 30100 Alès, France
| | - B de Wazières
- Service de médecine gériatrique, CHU de Nîmes, Place du Pr R Debré, 30000 Nîmes, France
| | - L Bernard
- Service de Maladies Infectieuses, CHU Hôpitaux de Tours, 37000 Tours, France
| | - M Paccalin
- Pôle de Gériatrie, CHU La Milétrie, 86000 Poitiers, France
| | - L Legout
- Service des maladies infectieuses et tropicales, CH Alpes Léman, Contamine sur Arve, France
| | - C Roubaud Baudron
- Pôle de Gérontologie Clinique, Université de Bordeaux, CHU Hôpitaux de Bordeaux, 33000 Bordeaux, France
| | - G Gavazzi
- Service Universitaire de Gériatrie Clinique, CHU de Grenoble, 38000 Grenoble, France
| | - T Fraisse
- Court séjour gériatrique, CH Alès Cévennes, Avenue du Docteur Jean Goubert, 30100 Alès, France.
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- Court séjour gériatrique, CH Alès Cévennes, Avenue du Docteur Jean Goubert, 30100 Alès, France; Service de maladies infectieuses, Centre Hospitalier Métropole Savoie, 73000 Chambéry, France; Service de médecine gériatrique, CHU de Nîmes, Place du Pr R Debré, 30000 Nîmes, France; Service de Maladies Infectieuses, CHU Hôpitaux de Tours, 37000 Tours, France; Pôle de Gériatrie, CHU La Milétrie, 86000 Poitiers, France; Service des maladies infectieuses et tropicales, CH Alpes Léman, Contamine sur Arve, France; Pôle de Gérontologie Clinique, Université de Bordeaux, CHU Hôpitaux de Bordeaux, 33000 Bordeaux, France; Service Universitaire de Gériatrie Clinique, CHU de Grenoble, 38000 Grenoble, France
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Abstract
Aim: In this study our aim was to evaluate the nosocomial infections and to understand factors affecting the cost of used antibiotics in palliative care unit.Materials and methods: Between 2016 and 2017, 113 patients were included in the study in palliative care unit of University of Health Sciences Bursa Yuksek Ihtisas Research and Training Hospital. Patients medical records were analyzed retrospectively for nosocomial infections, chronic diseases, presence of decubitis ulcers, opioid use, enteral, parenteral feedings, mortality and antibiotic cost.Results: Nosocomial infections were observed in 74.3% of the cases and 92.0% of patients used antibiotics. The mean duration of antibiotic use was 23.13 ± 18.06 days; and the average antibiotic cost was 2009.72 ± 2153.37 TL. Length of stay, male sex, presence of decubitus ulcers, tracheostomy, enteral and parenteral nutrition significantly increased antibiotic cost. Antibiotic cost and mortality were not related statistically.Conclusions: A vicious circle in palliative care involves the following order: length of stay, increased rate of infection, use of antibiotics, infection with resistant microorganisms, use of broad spectrum antibiotics, increased length of stay; all affecting each other. Therefore, using antibiotics for aggressive treatment of infections in palliative care is contraindicated as it opposes to real philosophy of palliative care.
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Affiliation(s)
- Ozgur Dagli
- Department of Infectious Diseases and Clinical Microbiology, Health Sciences University Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| | - Eyyup Tasdemir
- Department of Internal Medicine, Palliative Unit, Health Sciences University Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
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15
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Mirhosseini M, Oneschuk D, Hunter B, Hanson J, Quan H, Amigo P. The Role of Antibiotics in the Management of Infection-Related Symptoms in Advanced Cancer Patients. J Palliat Care 2019. [DOI: 10.1177/082585970602200202] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We prospectively evaluated the effect of antibiotic treatment on infection-related symptoms in patients with advanced cancer, in addition to assessing infection characteristics. Methods: A questionnaire was completed for enrolled patients using a personal digital assistant. Pre-antibiotic and post-antibiotic treatment Edmonton Symptom Assessment Scale (ESAS) scores were evaluated. Patient and the patient's physician identified infection-related symptoms experienced by the patient, which were documented under the “other” category on the ESAS. Pre-antibiotic and post-antibiotic scores of the patient and physician for the identified infection-related symptoms were evaluated. Results: Twenty-six patients on a tertiary palliative care unit with 31 episodes of infection were included for analysis. Patients’ pre- and post-antibiotic ESAS scores revealed a small improvement in all variables except anxiety. Patient assessment of symptoms related to infection showed a small improvement in all symptoms, with dsyuria being statistically significant. Physician assessment revealed a slight improvement for all the symptoms, although only cough was statistically significant. A general comparative physician assessment of patient outcome following antibiotic treatment suggested symptom improvement in 48.4% of patients. However, 50% of patients died within a week of antibiotic discontinuation. Conclusions: Antibiotic treatment appears to offer a mild improvement in infection-related symptoms. Patients reported the greatest improvement in dysuria, and physicians, in cough. Despite this symptomatic improvement, one quarter of the patients died within one week of antibiotic administration. Further comparative studies to evaluate symptomatic benefit, patient burden, and cost/benefit of antibiotic therapy in the treatment of infections in advanced cancer patients are required.
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Affiliation(s)
| | | | | | - John Hanson
- Department of Epidemiology, Cross Cancer Institute
| | - Hue Quan
- Edmonton Palliative Care Program, Edmonton, Alberta, Canada
| | - Pablo Amigo
- Edmonton Palliative Care Program, Edmonton, Alberta, Canada
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16
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Oneschuk D, Fainsinger R, Demoissac D. Antibiotic Use in the Last Week of Life in Three Different Palliative Care Settings. J Palliat Care 2019. [DOI: 10.1177/082585970201800105] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to examine the frequency and types of antibiotics prescribed in the last week of life in three different palliative care settings, including an acute care hospital, tertiary palliative care unit, and three hospice units. A total of 150 consecutive patients were evaluated, 50 in each of the three settings. Twenty-nine patients (58%) in the acute hospital setting, 26 (52%) in the tertiary palliative care unit, and 11(22%) in the hospice settings were prescribed antibiotics. In the acute care and tertiary palliative care settings, the most frequent route of antibiotic administration was intravenous and, in the hospice setting, oral. We conclude that there is marked variability in the numbers and types of antibiotics prescribed in these different palliative care settings in the last week of life. The high use of intravenous antibiotics and the large number of patients who were still receiving antibiotics at the time of death indicate the need for further prospective studies.
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Affiliation(s)
- Doreen Oneschuk
- Division of Palliative Care Medicine, Edmonton, Alberta, Canada
| | | | - Donna Demoissac
- Division of Palliative Care Medicine, Edmonton, Alberta, Canada
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17
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Juthani-Mehta M, Allore HG. Design and analysis of longitudinal trials of antimicrobial use at the end of life: to give or not to give? Ther Adv Drug Saf 2019; 10:2042098618820210. [PMID: 30800269 PMCID: PMC6378640 DOI: 10.1177/2042098618820210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 11/28/2018] [Indexed: 01/22/2023] Open
Abstract
This perspective review considers analytic features of the design of a longitudinal trial regarding antimicrobial therapy in older terminal cancer patients receiving palliative care. We first overview antimicrobial use at the end of life; both the potential hazards and benefits. Antimicrobial prescribing should consider both initiation as well as cessation of medications when analyzing the burden of medications. Approaches to decision making regarding antimicrobial use are presented and the importance of health literacy in these decision processes. We next present aspects of both feasibility and comparative trial design with a health literacy intervention to reduce antimicrobial use in older terminal cancer patients receiving palliative care. Considerations to clustered randomization and given that infections can reoccur over a trial period, we share suggestions of longitudinal modeling of clustered randomized trial data.
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Affiliation(s)
| | - Heather G Allore
- Yale University School of Medicine, 300 George St, Suite 775, New Haven, CT 06511, USA
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18
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Dyer J, Vaux L, Broom A, Broom J. Antimicrobial use in patients at the end of life in an Australian hospital. Infect Dis Health 2019; 24:92-97. [PMID: 30655096 DOI: 10.1016/j.idh.2018.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/14/2018] [Accepted: 12/16/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Antimicrobial resistance is increasing and there is an urgent international imperative to optimise use within hospitals. Antibiotic use at the end of life is frequent in the hospital setting, but data on use in Australian hospitals in this context is limited, and optimisation is complicated by clinical/diagnostic, ethical and humanistic considerations. As yet there is little data available on baseline use in hospital end of life settings, an empirical gap we sought to begin to fill here. METHODS A retrospective review of antibiotic use in patients who died in a Queensland hospital between January 2015 and July 2015. RESULTS One hundred and thirty-seven patients were included, of which 73 were male (53.3%) and the median age was 81 years. Of these patients, 86 received antibiotics at the end of life. The most common antibiotic prescribed was piperacillin/tazobactam (41.9%). The most common site of infection was pulmonary (32.8%). Of 86 patients prescribed antibiotics, 29 patients (33.7%) received antibiotics after futility was documented. 83 patients (96.5%) were administered their antibiotics intravenously. CONCLUSION Antimicrobial use at the end of life is frequent, with greater than one third of the patients who died in hospital having their antibiotics continued after discussion of futility. Antimicrobial use in this setting is complex with significant clinical, social and ethical considerations which need to be addressed if antibiotic optimization in this area (and more broadly in the hospital) is to be achieved.
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Affiliation(s)
- Jane Dyer
- Department of Medicine, Sunshine Coast Hospital and Health Service, Hospital Road, Nambour, QLD, 5470, Australia.
| | - Lucinda Vaux
- Department of Medicine, Sunshine Coast Hospital and Health Service, Hospital Road, Nambour, QLD, 5470, Australia
| | - Alex Broom
- School of Social Sciences, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Jennifer Broom
- Department of Medicine, Sunshine Coast Hospital and Health Service, Hospital Road, Nambour, QLD, 5470, Australia
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Jablonski L, Pruskowski J. Antimicrobial Therapy at the End of Life #351. J Palliat Med 2018; 21:718-719. [DOI: 10.1089/jpm.2018.0132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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20
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Antimicrobial therapy in palliative care: an overview. Support Care Cancer 2018; 26:1361-1367. [DOI: 10.1007/s00520-018-4090-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 01/30/2018] [Indexed: 11/27/2022]
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21
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Dincer M, Kahveci K, Doger C. An Examination of Factors Affecting the Length of Stay in a Palliative Care Center. J Palliat Med 2018. [DOI: 10.1089/jpm.2017.0147] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Metin Dincer
- Faculty of Health Sciences, Department of Health Management, Yıldırım Beyazıt University, Ankara, Turkey
- Ankara Ulus State Hospital, Ankara, Turkey
| | - Kadriye Kahveci
- Department of Intensive Care, Palliative Care and Anesthesiology, and Reanimation, Ankara Ulus State Hospital, Ankara, Turkey
| | - Cihan Doger
- Department of Anesthesiology and Reanimation, Ankara Ataturk Training and Research Hospital, Ankara, Turkey
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23
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Hui D, dos Santos R, Reddy S, Nascimento MSDA, Zhukovsky DS, Paiva CE, Dalal S, Costa ED, Walker P, Scapulatempo HH, Dev R, Crovador CS, De La Cruz M, Bruera E. Acute symptomatic complications among patients with advanced cancer admitted to acute palliative care units: A prospective observational study. Palliat Med 2015; 29:826-33. [PMID: 25881622 DOI: 10.1177/0269216315583031] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Limited information is available on the symptomatic complications that occur in the last days of life. AIM We documented the frequency, clinical course, and survival for 25 symptomatic complications among patients admitted to acute palliative care units. DESIGN Prospective longitudinal observational study. MEASUREMENTS Their attending physician completed a daily structured assessment of symptomatic complications from admission to discharge or death. SETTING/PARTICIPANTS We enrolled consecutive advanced cancer patients admitted to acute palliative care units at MD Anderson Cancer Center, USA, and Barretos Cancer Hospital, Brazil. RESULTS A total of 352 patients were enrolled (MD Anderson Cancer Center = 151, Barretos Cancer Hospital = 201). Delirium, pneumonia, and bowel obstruction were the most common complications, occurring in 43%, 20%, and 16% of patients on admission, and 70%, 46%, and 35% during the entire acute palliative care unit stay, respectively. Symptomatic improvement for delirium (36/246, 15%), pneumonia (52/161, 32%), and bowel obstruction (41/124, 33%) was low. Survival analysis revealed that delirium (p < 0.001), pneumonia (p = 0.003), peritonitis (p = 0.03), metabolic acidosis (p < 0.001), and upper gastrointestinal bleed (p = 0.03) were associated with worse survival. Greater number of symptomatic complications on admission was also associated with poorer survival (p < 0.001). CONCLUSION Symptomatic complications were common in cancer patients admitted to acute palliative care units, often do not resolve completely, and were associated with a poor prognosis despite active medical management.
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Affiliation(s)
- David Hui
- Department of Palliative Care & Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Renata dos Santos
- Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil
| | - Suresh Reddy
- Department of Palliative Care & Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Donna S Zhukovsky
- Department of Palliative Care & Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Shalini Dalal
- Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil
| | | | - Paul Walker
- Department of Palliative Care & Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Rony Dev
- Department of Palliative Care & Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Maxine De La Cruz
- Department of Palliative Care & Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative Care & Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Chae J, Quick BL. An examination of the relationship between health information use and health orientation in Korean mothers: focusing on the type of health information. JOURNAL OF HEALTH COMMUNICATION 2014; 20:275-284. [PMID: 25495418 DOI: 10.1080/10810730.2014.925016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The present study explores the relationship between mothers' health information use and health orientation regarding their children's health. Given that the online mothering community (i.e., parenting websites) is currently an important source of parenting information for mothers of young children, the present study distinguishes between informal online health information provided by mothering communities and formal online health information provided by health-related websites to test for differences. An online survey of 533 Korean mothers of children between the ages of 0 and 3 years revealed that the frequency of health-related website use (i.e., formal information) was associated with mothers' health consciousness and their health information orientation toward their children's health. The frequency of mothering community use (i.e., informal information) was associated with health information orientation, but not with health consciousness. Mass media use and contact with a health care professional for health information were not related to health consciousness or health information orientation. However, mothers' education level moderated the relationship between interpersonal communication and health consciousness, and between print media use and health information orientation. Results are discussed with an emphasis on the theoretical and practical implications of our findings.
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Affiliation(s)
- Jiyoung Chae
- a Department of Communication , University of Illinois at Urbana-Champaign , Urbana , Illinois , USA
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25
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Lo TJ, Wu HY, Ong WY, Lee A. An audit on antibiotic use at the end of life in inpatient hospice patients – Are we contributing to over-medicalization of dying? PROGRESS IN PALLIATIVE CARE 2014. [DOI: 10.1179/1743291x14y.0000000111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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26
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Mohammed AA, Al-Zahrani AS, Sherisher MA, Alnagar AA, EL-Shentenawy A, El-Kashif AT. The pattern of infection and antibiotics use in terminal cancer patients. J Egypt Natl Canc Inst 2014; 26:147-52. [DOI: 10.1016/j.jnci.2014.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 05/06/2014] [Accepted: 05/15/2014] [Indexed: 01/09/2023] Open
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Farrington N, Fader M, Richardson A, Prieto J, Bush H. Indwelling urinary catheter use at the end of life: a retrospective audit. ACTA ACUST UNITED AC 2014; 23:S4, S6-10. [PMID: 24820513 DOI: 10.12968/bjon.2014.23.sup9.s4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This audit aimed to measure: the prevalence of indwelling urinary catheters in patients at the end of life; the use of nursing documentation relating to catheter insertion and care; and prevalence of continence screening on admission. The audit involved a retrospective examination of case notes of patients who died on two oncology wards and a hospice at a large teaching hospital in the south of England. The audit showed that 63% of patients had an indwelling catheter during their admission. Documentation relating to urinary catheter insertion and care was present in 75% of cases, and 75% of patients received continence screening on admission. The findings confirm that indwelling urinary catheters are frequently used as a tool to manage urinary difficulties at the end of life, but that the indications for insertion and continued use can be unclear. Research is needed to establish appropriate use.
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Affiliation(s)
- Naomi Farrington
- Clinical Academic Fellow and Staff Nurse at the University of Southampton and University Hospital Southampton NHS Foundation Trust
| | - Mandy Fader
- Professor of Continence Technology at the University of Southampton and University Hospital Southampton NHS Foundation Trust
| | - Alison Richardson
- Clinical Professor in Cancer Nursing and End of Life Care at the University of Southampton and University Hospital Southampton NHS Foundation Trust
| | - Jacqui Prieto
- Senior Clinical Academic Research Fellow at the University of Southampton and University Hospital Southampton NHS Foundation Trust
| | - Harriet Bush
- Consultant in Palliative Medicine at the University of Southampton and University Hospital Southampton NHS Foundation Trust
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Yao CA, Hsieh MY, Chiu TY, Hu WY, Hung SH, Chen CY, Lee LT. Wishes of Patients With Terminal Cancer and Influencing Factors Toward the Use of Antibiotics in Taiwan. Am J Hosp Palliat Care 2014; 32:537-43. [DOI: 10.1177/1049909114540033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Context: The use of antibiotics is a common ethical dilemma in palliative care, thus identifying the concerns of patients with terminal cancer and respecting their wishes are important in making an ethically justified decision. Objectives: The aim of this study was to understand wishes of patients with terminal cancer and determine influencing factors toward the use of antibiotics. Methods: Two hundred and one patients with terminal cancer, admitted to a palliative care unit in Taiwan, completed a structured questionnaire interview, including demographic characteristics, knowledge and attitudes on antibiotics, the health locus of control, subjective norms, and the wishes to use antibiotics. Results: The most common misconception was “Antibiotics use is helpful to all terminal patients with infection,” which only 13.4% respondents disagreed. Of the 201patients, 92 (45.8%) expressed their wishes to use antibiotics even in the very terminal stage, and around one-fourth (26.4%) of patients wished not to use antibiotics, the remaining 27.8% were unclear. The most influential persons were medical professionals. The results of logistic regression analysis that showed familiarity with antibiotics, subjective norms, and the attitude toward burdens of antibiotics were the most significant predicting variables for those wishing to use antibiotics (odds ratio [OR] = 4.133, 95% confidence interval [CI] = 1.012-16.880; OR = 1.890, 95% CI = 1.077-3.317; and OR = 1.255, 95% CI = 1.047-1.503). Conclusion: This study indicated the responsibility of medical professionals to convey burdens of using antibiotics to patients and family. Otherwise, by enhancing professional training and performing effective communication with patients, we can reach a more appropriate decision in the use of antibiotics.
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Affiliation(s)
- Chien-An Yao
- Department of Family Medicine, Hospital and Medical College, National Taiwan University, Chong-Cheng District, Taipei City, Taiwan
| | - Meng-Yun Hsieh
- Department of Family Medicine, Hospital and Medical College, National Taiwan University, Chong-Cheng District, Taipei City, Taiwan
| | - Tai-Yuan Chiu
- Department of Family Medicine, Hospital and Medical College, National Taiwan University, Chong-Cheng District, Taipei City, Taiwan
| | - Wen-Yu Hu
- School of Nursing, Hospital and Medical College, National Taiwan University, Chong-Cheng District, Taipei City, Taiwan
| | - Shou-Hung Hung
- Department of Community and Family Medicine, Yun-Lin Branch Hospital and Medical College, National Taiwan University, Douliou City, Yunlin County, Taiwan
| | - Ching-Yu Chen
- Department of Family Medicine, Hospital and Medical College, National Taiwan University, Chong-Cheng District, Taipei City, Taiwan
| | - Long-Teng Lee
- Department of Family Medicine, Hospital and Medical College, National Taiwan University, Chong-Cheng District, Taipei City, Taiwan
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van Nordennen RTCM, Lavrijsen JCM, Vissers KCP, Koopmans RTCM. Decision Making About Change of Medication for Comorbid Disease at the End of Life: An Integrative Review. Drugs Aging 2014; 31:501-12. [DOI: 10.1007/s40266-014-0182-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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McKane J, Addie S, McGowan MC. A RETROSPECTIVE REVIEW OF ANTIMICROBIAL PRESCRIBING AND INFECTION PREVALENCE IN A PALLIATIVE CARE UNIT. BMJ Support Palliat Care 2014. [DOI: 10.1136/bmjspcare-2014-000654.168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Chih AH, Lee LT, Cheng SY, Yao CA, Hu WY, Chen CY, Chiu TY. Is It Appropriate To Withdraw Antibiotics in Terminal Patients with Cancer with Infection? J Palliat Med 2013; 16:1417-22. [DOI: 10.1089/jpm.2012.0634] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- An-Hsuan Chih
- Health Center, Office of Student Affairs, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Long-Teng Lee
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Chien-An Yao
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Wen-Yu Hu
- School of Nursing, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Ching-Yu Chen
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Tai-Yuan Chiu
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
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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; 46:483-90. [PMID: 23317761 PMCID: PMC3723720 DOI: 10.1016/j.jpainsymman.2012.09.010] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 09/04/2012] [Accepted: 09/19/2012] [Indexed: 10/27/2022]
Abstract
CONTEXT Antibiotic prescription in hospice patients is complicated by the focus on palliative rather than curative care and concerns regarding increasing antibiotic resistance. OBJECTIVES To estimate the antibiotic use in a national sample of hospice patients and identify facility and patient characteristics associated with antibiotic use in this population. METHODS This was an analysis of data from the 2007 National Home and Hospice Care Survey, a nationally representative sample of U.S. hospice agencies. We included data from 3884 patients who died in hospice care. The primary outcome measure was prevalence of antibiotic use in the last seven days of life. Diagnoses, including potential infectious indications for antibiotic use, were defined using International Classification of Diseases, Ninth Revision (ICD-9) codes. Chi-squared tests and t-tests were used to quantify associations of patient and facility characteristics with antibiotic use. RESULTS During the last seven days of life, 27% (95% CI: 24%-30%) of patients received at least one antibiotic and 1.3% (95% CI: 0.7%-2.0%) received three or more antibiotics. Among patients who received at least one antibiotic, 15% (95% CI: 10%-20%) had a documented infectious diagnosis compared with 9% (95% CI: 7%-11%), who had an infectious diagnosis but received no antibiotics. CONCLUSION In this nationally representative sample, 27% of hospice patients received an antibiotic during the last seven days of life, most without a documented infectious diagnosis. Further research is needed to elucidate the role of antibiotics in this patient population to maintain palliative care goals while reducing unnecessary antibiotic use.
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Affiliation(s)
- Jennifer S Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Karuppan CM. Healthcare tourism: Accelerating diffusion through a more effective use of communication channels. ACTA ACUST UNITED AC 2013. [DOI: 10.1179/cih.2010.3.1.24] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Thai V, Lau F, Wolch G, Yang J, Quan H, Fassbender K. Impact of infections on the survival of hospitalized advanced cancer patients. J Pain Symptom Manage 2012; 43:549-57. [PMID: 22071166 DOI: 10.1016/j.jpainsymman.2011.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 04/04/2011] [Accepted: 04/12/2011] [Indexed: 10/15/2022]
Abstract
CONTEXT Advanced cancer patients remain highly susceptible to infections, leading to significant morbidity and mortality. A lack of consensus on the management of infections in this population stems from the heterogeneity of the patient group, divergent goals of care, and unknown prognosis with antibiotic treatment. OBJECTIVES This prospective single cohort study examined the impact of infection and its treatment on the survival of hospitalized advanced cancer patients compared with a similar cohort without infection. METHODS A total of 441 patients were referred to the palliative care (PC) consult service in a tertiary hospital over a 12-month period. The occurrence of sepsis, organ-related infection, and antibiotic use were recorded on initial PC consult. Survival was calculated from the point of PC consult to the date of death. RESULTS Of these patients, 16.6% suffered a recent episode of sepsis (with or without an identifiable organ-related infection) and 23.4% had a recent episode of organ-related infection without clinically evident sepsis. Among the patients with sepsis, organ-related infection, or both, 89.7% received antibiotics (intravenous, oral, or both). Median survival of septic and nonseptic patients was 15 and 42 days, respectively. Septic patients who responded poorly to treatment (nonresponders) had a median survival of five days vs. 142 days in good responders. This equates with a hazard ratio of 9.74 for death in antibiotic nonresponders (P<0.05). Median survival for patients with an untreated organ-related infection (no sepsis) was 27 days compared with 48 days in a similar cohort receiving antibiotic therapy. Among patients on IV antibiotics, nonresponders had a median survival of six days vs. 108 days in responders. For patients on oral antibiotics, nonresponders had a median survival of six days vs. 70 days in responders. CONCLUSION These findings suggest that a recent episode of sepsis and/or organ-related infection significantly reduces overall patient survival. Favorable antibiotic response is associated with an increase in median survival. These findings suggest that antibiotic treatment may prolong survival, and a time-limited trial may be indicated contingent on goals of care.
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Affiliation(s)
- Vincent Thai
- University of Alberta Hospital, Edmonton, Alberta.
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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. [PMID: 22218916 DOI: 10.1177/1049909111432625] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We sought to evaluate antimicrobial use among patients with advanced cancer. METHODS Retrospective review of patients experiencing cancer-related death while hospitalized. RESULTS Among 145 patients, 126 (86.9%) received antimicrobials for a mean of 12.5 ± 12.9 days. 88 (69.8%) of 126 had clinical findings suggestive of infection. Sixty-one patients (48.4%) had positive cultures, the remaining were treated empirically. "Comfort care" was ultimately pursued in 99 (78.5%) of 126; 35 (35.4%) of 99 continued to receive antimicrobials after a transition to comfort care for an average of 1.6 ± 1.1 days. On average, antimicrobials were discontinued <1day prior to death. CONCLUSION Antimicrobial use was common among patients with advanced cancer. Even after transition to comfort care, more than one third of patients remained on antimicrobials. The risks and burdens of antimicrobials should be carefully examined when comfort is the stated goal.
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Affiliation(s)
- Andrew J Thompson
- Department of Internal Medicine Divisions of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA
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Stiel S, Krumm N, Pestinger M, Lindena G, Nauck F, Ostgathe C, Radbruch L, Elsner F. Antibiotics in palliative medicine--results from a prospective epidemiological investigation from the HOPE survey. Support Care Cancer 2011; 20:325-33. [PMID: 21274577 DOI: 10.1007/s00520-011-1084-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 01/03/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with advanced cancer are highly susceptible to infections. The decision whether to treat an active or suspected infection or to withhold or withdraw an antibiotic treatment in end-of-life care may be difficult. In order to quantify the antimicrobial prescribing practices and decision-making processes in palliative care units in Germany, a survey was performed as part of the Hospice and Palliative Evaluation in 2006. METHOD With a specifically designed questionnaire, 448 patients for whom an active or suspected infection and antibiotic treatment was discussed were documented. Data on the use of and indication for antibiotic treatment and the decision-making on withdrawal or withholding of antibiotic therapy were collected. RESULTS 286 (63.8%) received an antibiotic therapy. In 88 cases, withdrawal of an ongoing treatment was documented. The most frequent reasons for withdrawal were: deterioration of general status (41.4%), inefficiency of therapy (25.7%), and explicit wish of patient (14.3%; multiple answers possible). Outcome of antimicrobial therapy was rated poor or very poor for a fifth of the cases and accordingly, antibiotics were more likely to be withdrawn if the clinical success was considered to be poor. The initiation of therapy was often decided by physicians solely, whereas withdrawing and withholding therapy demanded more often involvement of other team members in the decision-making process. CONCLUSION The initiation of therapy seems to be easier than withdrawing and withholding, as involvement of other team members in the decision-making process was then sought more often. When antibiotics were given until death, the indication should be reconsidered because of a possibly undesirable prolongation of the dying process. Clinical practice may benefit from clear definitions of treatment goals and outcome criteria to better evaluate the necessity for and success of antimicrobial treatment.
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Affiliation(s)
- Stephanie Stiel
- Department of Palliative Medicine, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany.
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Nakagawa S, Toya Y, Okamoto Y, Tsuneto S, Goya S, Tanimukai H, Matsuda Y, Ohno Y, Eto H, Tsugane M, Takagi T, Uejima E. Can Anti-Infective Drugs Improve the Infection-Related Symptoms of Patients with Cancer during the Terminal Stages of Their Lives? J Palliat Med 2010; 13:535-40. [PMID: 20201665 DOI: 10.1089/jpm.2009.0336] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sari Nakagawa
- Department of Hospital Pharmacy Education, Graduate School of Pharmaceutical Science, Osaka University, Osaka, Japan
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Science, Kobe Gakuin University, Kobe, Japan
| | - Yoshie Toya
- Department of Hospital Pharmacy Education, Graduate School of Pharmaceutical Science, Osaka University, Osaka, Japan
| | - Yoshiaki Okamoto
- Department of Hospital Pharmacy Education, Graduate School of Pharmaceutical Science, Osaka University, Osaka, Japan
| | - Satoru Tsuneto
- Department of Palliative Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Sho Goya
- Department of Respiratory Medicine, Allergy, and Rheumatic Diseases, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hitoshi Tanimukai
- Department of Psychiatry, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yoichi Matsuda
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yumiko Ohno
- Department of Nursing, Osaka University Hospital, Osaka, Japan
| | - Hiroshi Eto
- Department of Hospital Pharmacy Education, Graduate School of Pharmaceutical Science, Osaka University, Osaka, Japan
| | - Mamiko Tsugane
- Department of Hospital Pharmacy Education, Graduate School of Pharmaceutical Science, Osaka University, Osaka, Japan
| | - Tatsuya Takagi
- Department of Pharmaceutical Information Science, Graduate School of Pharmaceutical Science, Osaka University, Osaka, Japan
- Department of Pharmainformatics and Metric Pharmaceutical Sciences, Graduate School of Pharmaceutical Science, Osaka University, Osaka, Japan
| | - Etsuko Uejima
- Department of Hospital Pharmacy Education, Graduate School of Pharmaceutical Science, Osaka University, Osaka, Japan
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Chun ED, Rodgers PE, Vitale CA, Collins CD, Malani PN. Antimicrobial use among patients receiving palliative care consultation. Am J Hosp Palliat Care 2009; 27:261-5. [PMID: 19959846 DOI: 10.1177/1049909109352336] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND We sought to characterize antimicrobial use among patients receiving palliative care consultation. METHODS Retrospective review of patients seen by the Palliative Care Service at the University of Michigan Health System from January 2008 to May 2008. RESULTS Of 131 patients seen in consultation, 70 received antimicrobials. We identified 92 infections among these 70 patients; therapy for 54 (58.7%) was empiric. Empiric therapy was most commonly prescribed for respiratory infection and urinary tract infection. Piperacillin/tazobactam (P/T) was the most frequently used agent, with 26 patients receiving P/T (37.1%); 22 of 26 received this agent empirically (84.6%, P = .005). Vancomycin was prescribed to 23 patients (32.9%). Sixteen patients (22.9%) died in hospital; another 31 were enrolled in hospice care. CONCLUSIONS Our results suggest significant use of empiric, broad-spectrum antimicrobial therapy among hospitalized patients near the end of life. We advocate for careful assessment of potential benefits and treatment burdens of antimicrobial therapy, especially when palliation is the goal.
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Affiliation(s)
- Erin Diviney Chun
- Department of Internal Medicine, Division of Geriatric Medicine, University of Michigan Health System, Ann Arbor, MI, USA
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Lee YJ, Park J, Widdows R. Exploring antecedents of consumer satisfaction and repeated search behavior on e-health information. JOURNAL OF HEALTH COMMUNICATION 2009; 14:160-173. [PMID: 19283539 DOI: 10.1080/10810730802659830] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
E-health information has become an important resource for people seeking health information. Even though many studies have been conducted to examine the quality of e-health information, only a few studies have explored the effects of the information seekers' motivations on the perceived quality of e-health information. There is even less information about repeated searches for e-health information after the users' initial experience of e-health information use. Using an online survey of information seekers, 252 e-health information users' responses were collected. The research examines the relationship among motivation, perceived quality, satisfaction, and intention to repeat-search e-health information. The results identify motivations to search e-health information and confirm the relationship among motivation, perceived quality dimensions, and satisfaction and intention to repeat searches for e-health information.
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Affiliation(s)
- Yun Jung Lee
- Purdue University, West Lafayette, Indianna 47907-2060, USA
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Béziaud N, Pavese P, Barnoud D, Laval G. [Bacterial infections in palliative care: antibiotics and therapeutic limitations]. Presse Med 2009; 38:935-44. [PMID: 19117717 DOI: 10.1016/j.lpm.2008.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2008] [Revised: 09/24/2008] [Accepted: 10/08/2008] [Indexed: 11/30/2022] Open
Abstract
The benefits of antibiotics treatments are not obvious at the end of life except for the symptomatic urinary infections. The numerous antibiotics prescribed raise economic and ecological problems in terms of bacterial resistances development and also in terms of quality of life. The control of symptoms has to be the main indication to prescribe antibiotics at the end of life. It is the general state, the prognostic of the patient, his wishes and those of his family, and his symptoms, controlled or not, that direct the decision to prescribe an antibiotic. Physicians must consider the objective of antibiotic treatment, the risk of side effects and the constraints related to this treatment before prescribing it for terminally ill people. They have to respect the bioethical principles, primarily the principles of beneficence, non-maleficience, and the respect to autonomy of the patient. In the event of decision of an antibiotic treatment at a patient at the end of the lifetime, the choice of this one must answer obviously the same requirements as in the other medical situations, within the framework of comprehensive and rigorous process.
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Affiliation(s)
- Nicolas Béziaud
- Equipe mobile de soins palliatifs et de coordination en soins de support, CHU de Grenoble, F-38043 Grenoble Cedex 09, France.
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41
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D'Agata E, Mitchell SL. Patterns of antimicrobial use among nursing home residents with advanced dementia. ACTA ACUST UNITED AC 2008; 168:357-62. [PMID: 18299489 DOI: 10.1001/archinternmed.2007.104] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Nursing home residents with advanced dementia are at high risk of infections and antimicrobial exposure near the end of life. Detailed studies quantifying antimicrobial prescribing practices among these residents have not been performed. METHODS A cohort of 214 residents with advanced dementia from 21 Boston-area nursing homes were followed up prospectively for 18 months or until death. We analyzed antimicrobial use, including type, indication, and quantity, by days of therapy per 1000 resident-days. RESULTS During an average of 322 days of follow-up, 142 residents (66.4%) with advanced dementia received at least 1 course of antimicrobial therapy (mean [SD] number of courses per resident, 4.0 [3.7]). The mean (SD) number of days of therapy per 1000 resident-days for the entire cohort was 53.0 (4.3). Quinolones and third-generation cephalosporins were the most commonly prescribed antimicrobials, accounting for 38.3% and 15.2%, respectively, of 540 prescribed antimicrobial therapy courses. A respiratory tract infection was the most common indication (46.7% of all antimicrobial therapy courses). Among 99 decedents, 42 (42.4%) received antimicrobials during the 2 weeks before death, of which 30 of 72 courses (41.7%) were administered via the parenteral route. The number of decedents receiving antimicrobials (P < .001), the number of antimicrobials prescribed (P = .01), and the days of therapy per 1000 resident-days (P < .001) increased significantly as subjects approached death. CONCLUSIONS Persons with advanced dementia are frequently exposed to antimicrobials, especially during the 2 weeks before death. The implications of this practice from the perspective of the individual treatment burden near the end of life and its contribution to the emergence of antimicrobial resistance in the nursing home setting need further evaluation.
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Affiliation(s)
- Erika D'Agata
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
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Soler Mieras A, Santaeugenia González S, Montané Esteva E. Antibióticos por vía subcutánea en pacientes que precisan cuidados paliativos. Med Clin (Barc) 2007; 129:236-7. [PMID: 17678607 DOI: 10.1157/13107924] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Aina Soler Mieras
- Servicio de Farmacología Clínica, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
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43
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Oh DY, Kim JH, Kim DW, Im SA, Kim TY, Heo DS, Bang YJ, Kim NK. Antibiotic use during the last days of life in cancer patients. Eur J Cancer Care (Engl) 2006; 15:74-9. [PMID: 16441680 DOI: 10.1111/j.1365-2354.2005.00603.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The purpose of this study is to document infection and to better understand current practice relating to antibiotic use and its effect in terminal cancer patients. We retrospectively reviewed patients with terminal stage cancer who were admitted to Seoul National University Boramae Hospital for symptom control only, and who finally died between March 2003 and April 2004. A total of 141 patients were enrolled. Mean duration from admission to death was 31.2 days. A total of 104 patients (75.2%) experienced a febrile episode, and physicians considered 113 patients (80.1%) developed a clinical infection. Total 119 patients (84.4%) received antibiotics. For 90 patients (63.8%), antibiotics were used until the day of death. After using antibiotics, 48% of fevers were controlled, and 31% of organism-proven cases were resolved. Symptomatic improvement of infection was achieved in 18 patients (15.1%), but 66 patients (55.4%) showed no improvement. Improved leucocytosis was achieved by 17% and C Reactive Protein elevation by 29%. In conclusion, our study reveals a high rate of infection and a high rate of antibiotic prescription during the last month of life in cancer patients. But symptomatic improvement was not achieved in more than half of the patients. Further study should be undertaken to clarify the benefit of antibiotics in terminal stage cancer patients.
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Affiliation(s)
- D Y Oh
- Seoul National University Boramae Hospital, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
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44
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Lam PT, Chan KS, Tse CY, Leung MW. Retrospective analysis of antibiotic use and survival in advanced cancer patients with infections. J Pain Symptom Manage 2005; 30:536-43. [PMID: 16376740 DOI: 10.1016/j.jpainsymman.2005.06.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2005] [Indexed: 01/09/2023]
Abstract
Infection is common among advanced cancer patients. This study was undertaken to review the pattern of use of antibiotics and to identify potential factors that could affect outcomes after infection. The medical records of all patients with advanced cancer who were enrolled into the palliative care service of a district hospital during the period January, 2002 to July, 2002 were retrospectively reviewed for infections and the use of antibiotics. Among the eligible 87 patients, 17 did not have any infective episode and 70 had at least one infective episode and accounted for a total of 120 episodes. Sixty-eight episodes were associated with survival for >14 days, and 52 episodes were associated with survival of < or =14 days. The most frequent sites of infection were chest (n=63, 52.5%), urinary tract (n=35, 29.2%), and skin/wound (n=6, 5%). Antibiotics were prescribed for 97.5% (n=117) episodes. The use of second-line antibiotics was 16.2% (n=19). By multivariate logistic regression analysis, dyspnea [odds ratio (OR)=2.6, 95% confidence interval (CI)=1.1-6.3], antibiotic utilization pattern [empirical therapy (OR=4.8, 95% CI=1.7-13.2) vs. therapy according to antibiotic sensitivity], and route of administration [parenteral route (OR=3.3, 95% CI=1.3-8.2) vs. oral route] were identified as independent determinants affecting survival after infection. Dyspnea was possibly associated with poor prognosis during the treatment of infections in patients with advanced cancer, and antibiotic therapy according to sensitivity was associated with better prognosis. Further studies are encouraged to verify this. The bioethical principles on the use of antibiotics as a life-sustaining treatment should always be followed.
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Affiliation(s)
- Po Tin Lam
- Division of Palliative Care, United Christian Hospital, Kowloon, Hong Kong
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45
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Ford PJ, Fraser TG, Davis MP, Kodish E. Anti-infective therapy at the end of life: ethical decision-making in hospice-eligible patients. BIOETHICS 2005; 19:379-92. [PMID: 16222854 DOI: 10.1111/j.1467-8519.2005.00450.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Clear guidelines addressing the ethically appropriate use of anti-infectives in the setting of hospice care do not exist. There is lack of understanding about key treatment decisions related to infection treatment for patients who are eligible for hospice care. Ethical concerns about anti-infective use at the end of life include: (1) delaying transition to hospice, (2) prolonging a dying process, (3) prescribing regimens incongruent with a short life expectancy and goals of care, (4) increasing the reservoir of potential resistant pathogens, (5) placing unreasonable costs on a capitated hospice system. Although anti-infectives are thought to be relatively safe, they can place a burden on patients and be inconsistent to particular care plans. The current complex, and at times fragmented, medical care often fails to address these issues in decision-making. In many ways, the ethics governing the end of life decisions related to dialysis, hydration/nutrition, and hypercalcemia parallel those of anti-infectives. In this article we articulate important elements in ethical decision-making in the application of anti-infectives for patients who are eligible for hospice care, and we point to the need for prospective studies to help refine particular guidelines in these cases.
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Affiliation(s)
- Paul J Ford
- The Department of Bioethics-JJ60, The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195, USA.
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46
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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; 30:175-82. [PMID: 16125033 DOI: 10.1016/j.jpainsymman.2005.03.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2005] [Indexed: 10/25/2022]
Abstract
Symptom control is one of the primary goals of hospice care. We prospectively followed patients with advanced cancer receiving outpatient hospice care to determine if the use of antimicrobials for a clinically suspected infection improved infection-related symptoms. During a 24-month period, 1,731 patients with a cancer diagnosis were admitted to a community-based outpatient hospice program. Over 89% of the patients had a Karnofsky performance of < or =60%. Six hundred twenty-three of 1,598 study patients were diagnosed with a total of 685 infections. Six hundred thirty-three of the infections were treated with antimicrobials for a clinically suspected infection. Symptoms were recorded, clinically indicated cultures were obtained, and antimicrobials were instituted at the discretion of the attending physician. Patients were subsequently monitored to determine the effects of antimicrobials on infection-related symptoms. A complete or a partial response of infection-related symptoms was observed in 79% of 265 patients with urinary tract infections, 43% of 221 patients with respiratory tract infections, 46% of 63 patients with oral cavity infections, 41% of 59 patients with skin or subcutaneous infections, and none of 25 patients with bacteremia. Fifty-two of the infections were not evaluable due to refusal of antimicrobials or receipt of less than 72 hours of antimicrobials. Patient survival in this study was not affected by the presence of infection or the use of antimicrobials. Although the use of antimicrobials improved symptoms in the majority of patients with urinary tract infections, symptom control was less successful in infections of the respiratory tract, mouth/pharynx, skin/subcutaneous tissue, or blood. Physicians should be aware of the limitations of the use of antimicrobials in patients with advanced cancer receiving hospice care. Treatment guidelines are proposed emphasizing the importance of patient preferences and the use of symptom control as the major indication for the use of antimicrobials in this patient population.
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Affiliation(s)
- Raquel E Reinbolt
- Walther Cancer Research Center, University of Notre Dame, Notre Dame, Indiana 46556, USA
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Barnabé C, Daeninck P. "Beauty is only skin deep": prevalence of dermatologic disease on a palliative care unit. J Pain Symptom Manage 2005; 29:419-22. [PMID: 15857746 DOI: 10.1016/j.jpainsymman.2004.08.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2004] [Indexed: 11/19/2022]
Abstract
Skin disease affects the palliative care patient population because of their immunosuppressed state and decreased mobility; however, the prevalence of skin disease in this population has not been studied. We collected dermatologic histories and examinations of patients admitted to a hospital-based tertiary palliative care unit. Repeat examinations were performed to assess the incidence of cutaneous disease, as well as the progression of existing conditions. Sixteen of 65 patients admitted during 9 consecutive weeks participated in regular examinations. Six patients developed decubitus ulcers or had progression of existing ulcers. Dermatitis, xerosis, and pruritus were common diagnoses. Six patients sustained cutaneous trauma. Of the 49 non-participating patients, 4 developed decubitus ulcers, 1 had a drug reaction, and 3 had cutaneous infections. Palliative care patients are prone to developing decubitus ulcers and cutaneous infections. Aggressive control of systemic symptoms may exacerbate skin disease. Consideration of dermatologic conditions is an important factor in optimizing skin control in this population.
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Affiliation(s)
- Cheryl Barnabé
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Finegan BA. Access denied; care impaired: the benefits of having online medical information available at the point-of-care. Anesth Analg 2004; 99:1450-1452. [PMID: 15502047 DOI: 10.1213/01.ane.0000132545.19806.3b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The availability of Internet-enabled computers in the operating room (OR) facilitates unparalleled physician access to current peer reviewed research, either in abstract or full text format, a development that provides physicians with an exciting opportunity to incorporate such findings into clinical practice at the point-of-care. In this report I describe how the availability of online peer reviewed medical literature altered, in one case a planned surgical procedure and, in the other, the interpretation by the anesthesiologist of the clinical significance of an intraoperative echocardiographic finding. In case one, a free, rather than an intact, internal mammary (IM) artery graft was placed to the left anterior descending coronary artery of a patient with renal failure and an ipsilateral upper extremity arteriovenous fistula. The change occurred after the full text results of a study indicating that steal could well occur during the initiation of dialysis if an intact IM was used were made available to the surgeon. In case two, the occurrence of mild central mitral regurgitation in a Carpentier-Edwards Perimount prosthetic mitral valve was confirmed to be a benign finding after a study detailing the long term performance characteristics of this valve was accessed online in the OR. The benefits and potential pitfalls of searching and interpreting online medical information are discussed.
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Affiliation(s)
- Barry A Finegan
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
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Ogle K, Greene DD, Winn B, Mishkin D, Bricker LG, Lambing AK. Completing a Life: Development of an Interactive Multimedia CD-ROM for Patient and Family Education in End-of-Life Care. J Palliat Med 2003; 6:841-50. [PMID: 14622471 DOI: 10.1089/109662103322515437] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There are relatively few comprehensive and empowering educational tools to assist people with terminal illness in addressing important end-of-life issues. Identifying this scarcity, a design team of health and multimedia professionals created an interactive, educational CD-ROM entitled Completing a Life. The primary goal of the project was to provide rich content in a style that was easy to access, understand, and use. The interactive medium of the CD-ROM enabled a large amount and wide array of material to be presented in manageable segments. These segments are connected by hyperlinks, providing self-guided control over the selection, pace, and order of material. The CD puts the learning experience in the hands of the learner. The format and design is also intended to generate a sense of empowerment, at a time and around issues often associated with a loss of control. Completing a Life covers a wide range of information for the user to choose from, spanning physical, emotional, family, and spiritual issues. A calm and comforting tone and welcoming environment enhances the users' ability to take in the information and make proactive decisions about his/her own well-being and care. The CD contains video narratives of individuals who tell their own stories of living with terminal illness. In addition to being a highly relevant means of conveying sensitive, health-related information, this collection of personal interviews may offer a form of "virtual support group" for the user. Finally, the interactive format allows stories and informational content to be linked in topic-specific ways that complement one another.
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Affiliation(s)
- Karen Ogle
- Department of Family Practice, Michigan State University, East Lansing, Michigan 48824, USA.
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Klemm P, Bunnell D, Cullen M, Soneji R, Gibbons P, Holecek A. Online cancer support groups: a review of the research literature. Comput Inform Nurs 2003; 21:136-42. [PMID: 12792194 DOI: 10.1097/00024665-200305000-00010] [Citation(s) in RCA: 188] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article explores current research on online cancer support groups. A review of the literature revealed 9 research articles (describing 10 research studies) that focused on computer-mediated or Internet cancer support groups. The researchers in 9 of the 10 studies concluded that online cancer support groups helped people cope more effectively with their disease. Most of the research studies had small sample sizes. Six of the 10 studies did not include men, and six focused on Caucasian women with breast cancer. Information seeking/giving was prevalent in the online groups. Gender differences, negative psychological effects, and barriers to using online groups were identified. The few studies that were found in the literature suffered from a lack of experimental design, small and homogenous samples, and lack of outcome measures, thereby limiting applicability of results.
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Affiliation(s)
- Paula Klemm
- Department of Nursing, University of Delaware, Newark, DE 19716, USA.
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