1
|
Goedken CC, Balkenende E, Livorsi D, Giannitrapani K, McCaa M, Clore G, Goto M, Marra AR, Perencevich EN. Improving shared decision-making around antimicrobial-prescribing during the end-of-life period: a qualitative study of Veterans, their support caregivers and their providers. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e89. [PMID: 38774117 PMCID: PMC11106728 DOI: 10.1017/ash.2024.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 05/24/2024]
Abstract
Objective Antimicrobials are frequently used for palliation during end-of-life care, but adverse effects, such as antimicrobial resistance, are a concern. Shared decision-making is beneficial in end-of-life care conversations to help align antimicrobial-prescribing with patient preferences. However, there is limited data regarding optimal incorporation of antimicrobial-prescribing discussions into shared decision-making conversations. We explored healthcare provider, patient, and support caregiver (eg, family member/friend) perceptions of barriers and facilitators to discussing antimicrobial-prescribing during the end-of-life period. Design Qualitative study. Participants Healthcare providers; palliative care/hospice care patients/caregivers. Methods We conducted semi-structured interviews on shared attitudes/beliefs about antimicrobial-prescribing during end-of-life patient care at one acute-care and one long-term-care facility. Interviews were analyzed for thematic content. Results Fifteen providers and 13 patients/caregivers completed interviews. Providers recognized the potential benefit of leveraging shared decision-making to guide antimicrobial-prescribing decisions. Barriers included limited face-to-face time with the patient and uncertainty of end-of-life prognosis. Patients/caregivers cited trust, comprehension, and feeling heard as important characteristics which act as facilitators in fostering effective shared decision-making around antimicrobial use. Communication in which providers ensure patients are involved in shared decision-making discussions could be increased to ensure patients and their providers develop a mutually agreeable care plan. Conclusions Shared decision-making is a practice that can guide antimicrobial-prescribing decisions during end-of-life care, thus potentially minimizing antimicrobial-related adverse effects. Our findings highlight opportunities for increased shared decision-making around antimicrobial use during end-of-life care. Interventions designed to address the identified barriers to shared decision-making have the potential to improve antimicrobial-prescribing practices at end-of-life.
Collapse
Affiliation(s)
- Cassie Cunningham Goedken
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
- University of Iowa, Carver College of Medicine, Iowa City, IA, USA
| | - Erin Balkenende
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
- University of Iowa, Carver College of Medicine, Iowa City, IA, USA
| | - Daniel Livorsi
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
- University of Iowa, Carver College of Medicine, Iowa City, IA, USA
| | - Karleen Giannitrapani
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
- Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Matthew McCaa
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Gosia Clore
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
- University of Iowa, Carver College of Medicine, Iowa City, IA, USA
| | - Michihiko Goto
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
- University of Iowa, Carver College of Medicine, Iowa City, IA, USA
| | - Alexandre R. Marra
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
- University of Iowa, Carver College of Medicine, Iowa City, IA, USA
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eli N. Perencevich
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
- University of Iowa, Carver College of Medicine, Iowa City, IA, USA
| |
Collapse
|
2
|
Kim NH, Han K, Ji E, Ahn S, Choi Y, Choi SJ, Moon SM, Song KH, Kim ES, Kim HB. Trends of antibiotic use at the end-of-life of cancer and non-cancer decedents: a nationwide population-based longitudinal study (2006-2018). ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e83. [PMID: 38751939 PMCID: PMC11094383 DOI: 10.1017/ash.2024.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/05/2024] [Accepted: 04/09/2024] [Indexed: 05/18/2024]
Abstract
Objective This study aimed to assess the actual burden of antibiotic use among end-of-life (EOL) patients in South Korea and to compare trends between cancer and non-cancer decedents. Design Population-based mortality follow-back study. Setting Data from the Korean National Health Insurance Database, covering the period from January1, 2006, to December 31, 2018, provided for research by the National Health Insurance Service (NHIS), were used. Participants All decedents from 2006 to 2018 were included and categorized as cancer decedents or non-cancer decedents. Methods Annual antibiotic consumption rates and prescription rates were calculated, and Poisson regression was used to estimate their trends. Results Overall antibiotic consumption rates decreased slightly among decedents in their final month with a less pronounced annual decrease rate among cancer decedents compared to non-cancer decedents (0.4% vs 2.3% per year, P <.001). Over the study period, although narrow spectrum antibiotics were used less, utilization and prescription of broad-spectrum antibiotics steadily increased, and prescription rates were higher in cancer decedents compared to non-cancer controls. Specifically, carbapenem prescription rates increased from 5.6% to 18.5%, (RR 1.087, 95% CI 1.085-1.088, P <.001) in cancer decedents and from 2.9% to 13.2% (RR 1.115, 95% CI 1.113-1.116, P <.001) in non-cancer decedents. Conclusions Our findings show that patients at the EOL, especially those with cancer, are increasingly and highly exposed to broad-spectrum antibiotics. Measures of antibiotic stewardship are required among this population.
Collapse
Affiliation(s)
- Nak-Hyun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Eunjeong Ji
- Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Soyeon Ahn
- Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yunsang Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Seong Jin Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Song Mi Moon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Kyoung-Ho Song
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Eu Suk Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| |
Collapse
|
3
|
Bae S, Kwon KT, Hwang S, Kim Y, Chang HH, Kim SW, Lee NY, Kim YK, Lee JC. Analysis of microbiological tests in patients withholding or withdrawing life-sustaining treatment at the end stage of life in 2 Korean hospitals. Infect Control Hosp Epidemiol 2024; 45:201-206. [PMID: 37694735 PMCID: PMC10877534 DOI: 10.1017/ice.2023.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/23/2023] [Accepted: 07/15/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE We evaluated the adequacy of microbiological tests in patients withholding or withdrawing life-sustaining treatment (WLST) at the end stage of life. SETTING The study was conducted at 2 tertiary-care referral hospitals in Daegu, Republic of Korea. DESIGN Retrospective cross-sectional study. METHODS Demographic findings, clinical and epidemiological characteristics, statistics of microbiological tests, and microbial species isolated from patients within 2 weeks before death were collected in 2 tertiary-care referral hospitals from January to December 2018. We also reviewed the antimicrobial treatment that was given within 3 days of microbiological testing in patients on WLST. RESULTS Of the 1,187 hospitalized patients included, 905 patients (76.2%) had WLST. The number of tests per 1,000 patient days was higher after WLST than before WLST (242.0 vs 202.4). Among the category of microbiological tests, blood cultures were performed most frequently, and their numbers per 1,000 patient days before and after WLST were 95.9 and 99.0, respectively. The positive rates of blood culture before and after WLST were 17.2% and 18.0%, respectively. Candida spp. were the most common microbiological species in sputum (17.4%) and urine (48.2%), and Acinetobacter spp. were the most common in blood culture (17.3%). After WLST determination, 70.5% of microbiological tests did not lead to a change in antibiotic use. CONCLUSIONS Many unnecessary microbiological tests are being performed in patients with WLST within 2 weeks of death. Microbiological testing should be performed carefully and in accordance with the patient's treatment goals.
Collapse
Affiliation(s)
- Sohyun Bae
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Ki Tae Kwon
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Soyoon Hwang
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Yoonjung Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Hyun-Ha Chang
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Shin-Woo Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Nan Young Lee
- Department of Clinical Pathology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Yu Kyoung Kim
- Department of Clinical Pathology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Je Chul Lee
- Department of Microbiology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| |
Collapse
|
4
|
Wi YM, Kwon KT, Hwang S, Bae S, Kim Y, Chang HH, Kim SW, Cheong HS, Lee S, Jung DS, Sohn KM, Moon C, Heo ST, Kim B, Lee MS, Hur J, Kim J, Yoon YK. Use of Antibiotics Within the Last 14 Days of Life in Korean Patients: A Nationwide Study. J Korean Med Sci 2023; 38:e66. [PMID: 36880107 PMCID: PMC9988432 DOI: 10.3346/jkms.2023.38.e66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/06/2022] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Antimicrobial prescriptions for serious chronic or acute illness nearing its end stages raise concerns about the potential for futile use, adverse events, increased multidrug-resistant organisms, and significant patient and social cost burdens. This study investigated the nationwide situation of how antibiotics are prescribed to patients during the last 14 days of life to guide future actions. METHODS This nationwide multicenter retrospective cohort study was conducted at 13 hospitals in South Korea from November 1 to December 31, 2018. All decedents were included in the study. Antibiotic use during the last two weeks of their lives was investigated. RESULTS A total of 1,201 (88.9%) patients received a median of two antimicrobial agents during the last two weeks of their lives. Carbapenems were prescribed to approximately half of the patients (44.4%) in the highest amount (301.2 days of therapy per 1,000 patient-days). Among the patients receiving antimicrobial agents, 63.6% were inappropriate and only 327 patients (27.2%) were referred by infectious disease specialists. The use of carbapenem (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.13-2.03; P = 0.006), underlying cancer (OR, 1.56; 95% CI, 1.20-2.01, P = 0.047), underlying cerebrovascular disease (OR, 1.88; 95% CI, 1.23-2.89, P = 0.004), and no microbiological testing (OR, 1.79; 95% CI, 1.15-2.73; P = 0.010) were independent predictors for inappropriate antibiotic prescribing. CONCLUSION A considerable number of antimicrobial agents are administered to patients with chronic or acute illnesses nearing their end-of-life, a high proportion of which are prescribed inappropriately. Consultation with an infectious disease specialist, in addition to an antimicrobial stewardship program, may be necessary to induce the optimal use of antibiotics.
Collapse
Affiliation(s)
- Yu Mi Wi
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Ki Tae Kwon
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea.
| | - Soyoon Hwang
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sohyun Bae
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yoonjung Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hyun-Ha Chang
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Shin-Woo Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hae Suk Cheong
- Division of Infectious Diseases, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shinwon Lee
- Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dong Sik Jung
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Kyung Mok Sohn
- Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Chisook Moon
- Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Sang Taek Heo
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, Jeju National University, Jeju, Korea
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Mi Suk Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Jian Hur
- Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Jieun Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | | |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Marra AR, Clore GS, Balkenende E, Goedken CC, Livorsi DJ, Goto M, Vaughan-Sarrazin MS, Broderick A, Perencevich EN. Association of entry into hospice or palliative care consultation during acute care hospitalization with subsequent antibiotic utilization. Clin Microbiol Infect 2023; 29:107.e1-107.e7. [PMID: 35931374 DOI: 10.1016/j.cmi.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/12/2022] [Accepted: 07/16/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE We aimed to estimate antibiotic use during the last 6 months of life for hospitalized patients under hospice or palliative care and identify potential targets (i.e. time points) for antibiotic stewardship during the end-of-life period. METHODS We conducted a retrospective cohort study of nationwide Veterans Affairs (VA) patients who died between January 1, 2014 and December 31, 2019 and who had been hospitalized within 6 months prior to death. Data from the VA's integrated electronic medical record were collected, including demographics, comorbid conditions, and duration of inpatient antibiotics administered, along with outpatient antibiotics dispensed. A propensity score-matched cohort analysis was conducted to compare antibiotic use between hospitalized patients placed into palliative care or hospice matched to hospitalized patients not receiving palliative care or hospice. RESULTS There were 9808 and 40 796 propensity score-matched patient pairs in the hospice and palliative care groups, respectively. Within 14 days of placement or consultation, 41% (4040/9808) of hospice patients and 48% (19 735/40 796) of palliative care patients received at least one antibiotic, while 25% (2420/9808) matched nonhospice and 27% (10 991/40 796) matched nonpalliative care patients received antibiotics. Entry into hospice was independently associated with a 12% absolute increase in antibiotic prescribing, and entry into palliative care was associated with a 17% absolute increase during the 14 days post-entry vs. pre-entry period. DISCUSSION We observed that patients receiving end-of-life care had high levels of antibiotic exposure across this VA population, particularly during admissions when they received hospice or palliative care consultation.
Collapse
Affiliation(s)
- Alexandre R Marra
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA; Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | - Gosia S Clore
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Erin Balkenende
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Cassie Cunningham Goedken
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Daniel J Livorsi
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Michihiko Goto
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Mary S Vaughan-Sarrazin
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Ann Broderick
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Eli N Perencevich
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| |
Collapse
|
7
|
Larnard J, Blackshear L, Lee MSL, Buss MK, Stead W. Perceptions and Reality of Antimicrobial Prescribing During the Transition to Comfort Measures Only at an Academic Medical Center. Open Forum Infect Dis 2022; 10:ofac692. [PMID: 36686640 PMCID: PMC9850271 DOI: 10.1093/ofid/ofac692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/22/2022] [Indexed: 12/27/2022] Open
Abstract
Background Little is known about antimicrobial prescribing when patient care is transitioned to comfort measures only (CMO). We used a multidisciplinary survey and retrospective cohort study to gain insight into antimicrobial prescribing in this population at an academic medical center to inform future antimicrobial stewardship interventions. Methods A survey focusing on antimicrobial prescribing during the transition to CMO was electronically distributed to providers in medical subspecialities and responses were compared across specialties. A retrospective chart review was performed of patients admitted to an academic medical center in 2020 who were on antimicrobials in the 48 hours prior to CMO. We investigated the percentage of patients who remained on antimicrobials after the transition to CMO and rationale for continuing antimicrobials. Results We received 113 survey responses (35% response rate). Forty-one percent of respondents indicated that they "sometimes" or "often" continued antimicrobials during the transition to CMO. Patient/family preference and symptom palliation were the most common factors cited by respondents when deciding whether to continue antimicrobials in this population. Of the 546 patient charts reviewed, 140 (26%) patients were alive 48 hours after CMO order, and 19 (14%) of those patients remained on antimicrobials. Five of 19 (26%) patients had documentation that antimicrobials were continued due to patient/family preference and 5 of 19 (26%) patients had documentation that antimicrobials were continued for palliation of symptoms. Conclusions Patient/family preference and symptom palliation are important factors in prescribing antimicrobials when patient care is transitioned to CMO. More evidence is needed regarding palliative benefits of antibiotics to inform provider discussions of benefits and harms of antimicrobial use in this setting.
Collapse
Affiliation(s)
- Jeffrey Larnard
- Correspondence: Jeffrey Larnard, MD, Division of Infectious Disease, Beth Israel Deaconess Medical Center, 110 Francis St, Suite GB, Boston, MA 02215 ()
| | - Leslie Blackshear
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Matthew Shou Lun Lee
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Mary K Buss
- Department of Palliative Care, Tufts Medical Center, Boston, Massachusetts, USA
| | | |
Collapse
|
8
|
Kates OS, Krantz EM, Lee J, Klaassen J, Morris J, Mezheritsky I, Sweet A, Tverdek F, Loggers ET, Pergam SA, Liu C. Association of Physician Orders for Life-Sustaining Treatment With Inpatient Antimicrobial Use at End of Life in Patients With Cancer. Open Forum Infect Dis 2021; 8:ofab361. [PMID: 34395710 PMCID: PMC8360239 DOI: 10.1093/ofid/ofab361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/02/2021] [Indexed: 11/14/2022] Open
Abstract
Background Antimicrobial utilization at end of life is common, but whether advance directives correlate with usage is unknown. We sought to determine whether Washington State Physician Orders for Life Sustaining Treatment (POLST) form completion or antimicrobial preferences documented therein correlate with subsequent inpatient antimicrobial prescribing at end of life. Methods This was a single-center, retrospective cohort study of adult patients at a cancer center who died between January 1, 2016, and June 30, 2019. We used negative binomial models adjusted for age, sex, and malignancy type to test the relationship between POLST form completion ≥30 days before death, antimicrobial preferences, and antimicrobial days of therapy (DOT) per 1000 inpatient-days in the last 30 days of life. Results Among 1295 eligible decedents with ≥1 inpatient-day during the last 30 days of life, 318 (24.6%) completed a POLST form. Of 318, 120 (37.7%) were completed ≥30 days before death, 35/120 (29.2%) specified limited antimicrobials, 55/120 (45.8%) specified full antimicrobial use, and 30/120 (25%) omitted antimicrobial preference. Eighty-three percent (1070/1295) received ≥1 inpatient antimicrobial. The median total and intravenous (IV) antimicrobial DOT/1000 inpatient-days were 1077 and 667. Patients specifying limited antimicrobials had significantly lower total antimicrobial DOT (adjusted incidence rate ratio [IRR], 0.68; 95% CI, 0.49-0.95; P = .02) and IV antimicrobial DOT (IRR, 0.57; 95% CI, 0.38-0.86; P = .008) compared with those without a POLST. Conclusions Indicating a preference for limited antimicrobials on a POLST form ≥30 days before death may lead to less inpatient antimicrobial use in the last 30 days of life.
Collapse
Affiliation(s)
- Olivia S Kates
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA.,Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Elizabeth M Krantz
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Juhye Lee
- Department of Basic Sciences and Computational Biology Program, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - John Klaassen
- Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - Jessica Morris
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | | | - Ania Sweet
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - Frank Tverdek
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - Elizabeth T Loggers
- Seattle Cancer Care Alliance, Seattle, Washington, USA.,Division of Oncology, University of Washington, Seattle, Washington, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Steven A Pergam
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA.,Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - Catherine Liu
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA.,Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Seattle Cancer Care Alliance, Seattle, Washington, USA
| |
Collapse
|
9
|
Datta R, Topal J, McManus D, Sanft T, Dembry LM, Morrison LJ, Quagliarello V, Juthani-Mehta M. Education needed to improve antimicrobial use during end-of-life care of older adults with advanced cancer: A cross-sectional survey. Palliat Med 2021; 35:236-241. [PMID: 32928066 DOI: 10.1177/0269216320956811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Antimicrobial use during end-of-life care of older adults with advanced cancer is prevalent. Factors influencing the decision to prescribe antimicrobials during end-of-life care are not well defined. AIM To evaluate factors influencing medicine subspecialists to prescribe intravenous and oral antimicrobials during end-of-life care of older adults with advanced cancer to guide an educational intervention. DESIGN 18-item single-center cross-sectional survey. SETTING/PARTICIPANTS Inpatient medicine subspecialists in 2018. RESULTS Of 186 subspecialists surveyed, 67 (36%) responded. Most considered withholding antimicrobials at the time of clinical deterioration during hospitalization (n = 54/67, 81%), viewed the initiation of additional intravenous antimicrobials as escalation of care (n = 44/67, 66%), and believed decision-making should involve patients or surrogates and providers (n = 64/67, 96%). Fifty-one percent (n = 30/59) of respondents who conducted advance care planning did not discuss antimicrobials. Barriers to discussing end-of-life antimicrobials included the potential to overwhelm patients or families, challenges of withdrawing antimicrobials, and insufficient training. CONCLUSIONS Although the initiation of additional intravenous antimicrobials was viewed as escalation of care, antimicrobials were not routinely discussed during advance care planning. Educational interventions that promote recognition of antimicrobial-associated adverse events, incorporate antimicrobial use into advance care plans, and offer communication simulation training around the role of antimicrobials during end-of-life care are warranted.
Collapse
Affiliation(s)
- Rupak Datta
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA.,Hospital Epidemiology and Infection Prevention Program, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Jeffrey Topal
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA.,Department of Pharmacy Services, Yale New Haven Hospital, New Haven, CT, USA
| | - Dayna McManus
- Department of Pharmacy Services, Yale New Haven Hospital, New Haven, CT, USA
| | - Tara Sanft
- Yale Medical Oncology, Smilow Cancer Hospital at Yale New Haven Hospital, New Haven, CT, USA
| | - Louise Marie Dembry
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA.,Hospital Epidemiology and Infection Prevention Program, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.,Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Laura J Morrison
- Palliative Care Program, Smilow Cancer Hospital at Yale New Haven Hospital, New Haven, CT, USA
| | | | - Manisha Juthani-Mehta
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA.,Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| |
Collapse
|
10
|
Morioka S, Mori M, Suzuki T, Yokomichi M, Hamano J, Morita T. Determinants of Physicians' Attitudes Toward the Management of Infectious Diseases in Terminally Ill Patients With Cancer. J Pain Symptom Manage 2020; 60:1109-1116.e2. [PMID: 32634472 DOI: 10.1016/j.jpainsymman.2020.06.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/15/2020] [Accepted: 06/30/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Antimicrobials are frequently prescribed to terminally ill patients with cancer; however, physicians' practice patterns regarding antimicrobial use vary widely. This study aimed to systematically identify factors that determine physicians' attitudes toward the management of infectious diseases in terminally ill patients with cancer. METHODS A nationwide cross-sectional survey involving 600 oncologists, 600 infectious diseases physicians, 600 palliative care physicians, and 220 home care physicians was conducted between November 2017 and January 2018. The primary endpoint was physicians' attitudes toward the management of infectious diseases in terminally ill patients with cancer with a few weeks of prognosis. Physicians' beliefs regarding management of infectious diseases as well as physician-perceived "good death" were also assessed (1 = strongly disagree to 6 = strongly agree). RESULTS There were 895 (44.3%) analyzable response, and average scores of physicians' attitudes ranged between 2.69 and 4.32. In total, 241 (27%; 95% CI = 24-30) to 691 (78%; 95% CI = 75-81) respondents showed proactive attitudes toward various infectious diseases management. In linear regression analysis, determinants of proactive attitudes included the following: physicians' belief that examination and treatment will improve quality of life and prognosis and reduce suffering (β = 0.32, t = 9.99, P = 0.00); greater physician-perceived importance on receiving enough treatment (β = 0.09, t = 2.88, P = 0.00) and less importance on dying a natural death (β = -0.07, t = -2.14, P = 0.03) for a "good death"; working at a tertiary care hospital (β = 0.16, t = 4.40, P = 0.00); and not being a home care physician (β = -0.20, t = -5.51, P = 0.00) or palliative care physician (β = -0.12, t = -3.64, P = 0.00). CONCLUSIONS Physicians have divergent attitudes toward the management of infectious diseases in terminally ill patients with cancer. Reflection by physicians on their own beliefs and perceptions regarding infectious disease management and a "good death" may help provide the best end-of-life care.
Collapse
Affiliation(s)
- Shinichiro Morioka
- Disease Control and Prevention Center, National Centre for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan.
| | - Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Tomomi Suzuki
- Division of Palliative Medicine, Shizuoka Cancer Center, Mishima, Shizuoka, Japan
| | - Marika Yokomichi
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Jun Hamano
- Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Tatsuya Morita
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| |
Collapse
|
11
|
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.
Collapse
|
12
|
Lopez S, Vyas P, Malhotra P, Finuf K, Magalee C, Nouryan C, Hirsch B. A Retrospective Study Analyzing the Lack of Symptom Benefit With Antimicrobials at the End of Life. Am J Hosp Palliat Care 2020; 38:391-395. [PMID: 32830525 DOI: 10.1177/1049909120951748] [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: 11/15/2022] Open
Abstract
BACKGROUND Infections are common in terminally ill patients (pts), and although antibiotics are frequently prescribed, their benefit for symptom relief is not clear. Antimicrobials at the end of life (EOL) may increase the risk of antimicrobial resistance and Clostrioides difficile infection. Our aim was to determine the frequency of symptom occurrence at the EOL when comparing pts who did or did not receive antibiotics (AB+ or AB-). METHODS We reviewed electronic medical records of pts admitted to a palliative care unit of a quarternary care hospital between 01/09/2017 and 07/16/2017 and assessed antimicrobial use in the last 14 days of life. Differences in demographics and symptom control between AB+ and AB- pts were analyzed using chi-square analyses; p-values were computed using Mann-Whitney tests. RESULTS Of a total of 133 pts included, 90 (68%) received antimicrobials (AB+). The indication for antibiotics was documented in only 12% of pts. The AB+ and AB- groups were similar with respect to demographics, including sex, and Charleston Comorbidity Index except for age (p = 0.01) and race (p = 0.03). Documented infections were similar between AB+ and AB- groups, except urinary tract infections. No statistically significant differences were noted in documented symptoms including pain, dyspnea, fever, lethargy, and alteration of mental state or length of stay. CONCLUSION Our study did not show differences in frequencies of documented symptoms with use of antimicrobials at EOL. Antimicrobial stewardship programs and further research can help with developing EOL care antimicrobial guidelines supporting patients and providers through shared decision-making.
Collapse
Affiliation(s)
- Santiago Lopez
- Department of Medicine, 24945Northwell Heath, New York, NY, USA
| | - Pooja Vyas
- Department of Medicine, 24945Northwell Heath, New York, NY, USA
| | | | - Kayla Finuf
- Department of Medicine, 24945Northwell Heath, New York, NY, USA
| | | | | | - Bruce Hirsch
- Department of Medicine, 24945Northwell Heath, New York, NY, USA
| |
Collapse
|
13
|
Kwon KT. Implementation of Antimicrobial Stewardship Programs in End-of-Life Care. Infect Chemother 2019; 51:89-97. [PMID: 31270988 PMCID: PMC6609743 DOI: 10.3947/ic.2019.51.2.89] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Indexed: 12/17/2022] Open
Abstract
Many terminal patients at the end-of-life have been receiving antimicrobial therapy despite concerns including futile use, potential lack of efficacy, increased patient burden, excess costs, high risk of adverse effects, and increased antimicrobial resistance. Thus, the implementation of antimicrobial stewardship programs (ASPs) in end-of-life care needs to be discussed. But, the topics of antimicrobial therapy and ASPs have not been addressed in the Life-Sustaining Treatment Decision Act enacted in the Korea in February 2016. Antimicrobial therapy should be included in the decision-making framework for end-of-life care similar to other life-sustaining treatment decisions. If the antimicrobial therapy is legally considered as a life-sustaining treatment which can be withdrawn or withheld in patients at the end-of-life, the feasibility of implementing ASPs among this patient population may improve. Various researches on antimicrobial therapy for patients at the end-of-life need to be conducted and collaborations are required between ASPs professionals and many other concerned parties involved in the legislative process of the Life-Sustaining Treatment Decision Act. This review aims to summarize previous studies on the use of antimicrobials for end-of-life care and reveal important aspects for applying ASPs to this population in Korea.
Collapse
Affiliation(s)
- Ki Tae Kwon
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
| |
Collapse
|