High Frequency of Antimicrobials Use in Palliative Care: Are We Moving in the Right Direction?

Determinants of Physicians' Attitudes Toward the Management of Infectious Diseases in Terminally Ill Patients With Cancer

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.

Antimicrobial prescribing in patients with advanced-stage illness in the antimicrobial stewardship era

OBJECTIVE

Antimicrobials are frequently administered to patients with an advanced-stage illness. Understanding the current practice of antimicrobial use at the end of life and the factors influencing physicians' prescribing behavior is necessary to develop an effective antimicrobial stewardship program and to provide optimal end-of-life care for terminally ill patients.

DESIGN

A 1-year retrospective cohort study.

SETTING

A public tertiary-care center.PatientsThe study included 260 adult patients who were hospitalized and later died at the study institution with an advanced-stage illness.

RESULTS

Of 260 patients in our study cohort, 192 (73.8%) had an advanced-stage malignancy and 136 (52.3%) received antimicrobial therapy in the last 14 days of their life; of the latter, 60 (44.1%) received antimicrobials for symptom relief. Overall antimicrobial use in the last 14 days of life was 421.9 days of therapy per 1,000 patient days. Factors associated with antimicrobial use in this period included a history of antimicrobial use prior to the last 14 days of life during index hospitalization (adjusted odds ratio [aOR], 4.86; 95% confidence interval [CI], 2.67-8.84) and antipyretic use in the last 14 days of life (aOR, 4.19; 95% CI, 2.01-8.71).

CONCLUSION

Approximately half of the patients hospitalized with an advanced-stage illness received antimicrobials in the last 14 days of life. The factors associated with antimicrobial use at the end of life in this study are likely to explain physicians' prescribing behaviors. In the current era of antimicrobial stewardship, reconsidering antimicrobial use in terminally ill patients is necessary.