Pneumonia in Nursing Home Patients With Advanced Dementia: Decisions, Intravenous Rehydration Therapy, and Discomfort

Use of antimicrobial agents in actively dying inpatients after suspension of life-sustaining treatments: Suggestion for antimicrobial stewardship

BACKGROUND

The role of antimicrobial treatment in end-of-life care has been controversial, whether antibiotics have beneficial effects on comfort and prolonged survival or long-term harmful effects on increasing antimicrobial resistance. We assessed the use of antimicrobial agents and factors associated with de-escalation in inpatients who suspended life-sustaining treatments (SLST) and immediately died.

METHODS

We included 1296 (74.7%) inpatients who died within 7 days after SLST out of 1734 patients who consented to SLST on their own or family's initiative following a decision by two physicians, observing the "Life-sustaining Treatment Decision Act" between January 2020 and December 2020 at two teaching hospitals. De-escalation was defined as changing to narrower spectrum anti-bacterial drugs or stopping ≥ one antibiotic of combined treatment.

RESULTS

90.6% of total patients received anti-bacterial agents, particularly a combination treatment in 60.1% and use of ≥ three drugs in 18.2% of them. Antifungal and antiviral drugs were administered to 12.6% and 3.3% of the patients on SLST, respectively. Antibacterial and antifungal agents were withdrawn in only 8.3% and 1.3% of the patients after SLST, respectively. Anti-bacterial de-escalation was performed in 17.0% of patients, but 43.6% of them received more or broad-spectrum antibiotics after SLST. In multivariate regression, longer hospital stays before SLST, initiation of SLST in the intensive care unit, and cardiovascular diseases were independently associated with anti-bacterial de-escalation after SLST.

CONCLUSIONS

The intervention for substantial antibiotic use in patients on SLST should be carefully considered as antimicrobial stewardship after decision by the will of the patient and proxy.

For the interprofessional management of the discomfort of long-term care facility residents with dementia

Educating interprofessional practitioners in long-term care facilities (LTCFs) is critical for managing discomfort of residents with dementia, which is often unnoticed and undertreated. A framework of education on discomfort management that is applicable in various environments in different facilities is necessary. We developed a preliminary framework to educate interprofessional practitioners on discomfort management of dementia residents in LTCFs. We conducted a three-step research process: a literature review using topic modeling, in-depth interviews, and Delphi surveys. We derived four categories for an interprofessional approach toward discomfort management education in LTCFs: identifying visual and nonvisual signs to communicate among professionals, close observation using comparison and contrast to share information for discomfort care, harmony in interprofessional roles, and applying common and specific professional knowledge for discomfort management. The findings provide the first outline for an educational framework for interprofessional discomfort management in LTCFs for residents with dementia. We recommend interventions across different cultures to verify the framework in future research.

Palliative Care in Advanced Dementia: Comparison of Strategies in Three Countries

Palliative care including hospice care is appropriate for advanced dementia, but policy initiatives and implementation have lagged, while treatment may vary. We compare care for people with advanced dementia in the United States (US), The Netherlands, and Israel. We conducted a narrative literature review and expert physician consultation around a case scenario focusing on three domains in the care of people with advanced dementia: (1) place of residence, (2) access to palliative care, and (3) treatment. We found that most people with advanced dementia live in nursing homes in the US and The Netherlands, and in the community in Israel. Access to specialist palliative and hospice care is improving in the US but is limited in The Netherlands and Israel. The two data sources consistently showed that treatment varies considerably between countries with, for example, artificial nutrition and hydration differing by state in the US, strongly discouraged in The Netherlands, and widely used in Israel. We conclude that care in each country has positive elements: hospice availability in the US, the general palliative approach in The Netherlands, and home care in Israel. National Dementia Plans should include policy regarding palliative care, and public and professional awareness must be increased.

Trends in antibiotics use among long-term US nursing-home residents

OBJECTIVES

Antibiotics are overly prescribed in nursing homes. Recent antibiotic stewardship efforts attempt to reduce inappropriate use. Our objective was to describe antibiotic use from 2012 to 2016 among nursing-home residents with various health conditions.

DESIGN

Retrospective, repeated cross-sectional analysis.

SETTING AND PARTICIPANTS

All long-term residents in a random 10% sample of national nursing homes: 2,092,809 assessments from 319,615 nursing-home residents in 1,562 nursing homes.

MEASUREMENTS

We calculated a 1-day antibiotic prevalence using all annual and quarterly clinical assessments in the Minimum Data Set (MDS) from April 2012 through December 2016. We calculated prevalence of antibiotic use overall and within conditions of interest: Alzheimer's disease and related dementias (ADRD), advanced cognitive impairment (ACI), and infections likely to be treated with antibiotics. We applied logistic regressions with nursing-home cluster, robust standard errors to assess changes in conditions and antibiotic use 2012-2016.

RESULTS

Overall, antibiotic use did not change (2012 vs 2016, adjusted odds ratio [AOR], 1.00; 95% CI, 0.97-1.03). Antibiotic use was higher in 2016 versus 2012 among assessments with any infection (AOR, 1.10; 95% CI, 1.04-1.16), urinary tract infection (AOR, 1.18; 95% CI, 1.12-1.25), and no infection (AOR, 1.13; 95% CI, 1.09-1.17). Results were similar by cognitive status.

CONCLUSIONS

The increased proportion of assessments recording antibiotics but no infection may not be clinically appropriate. Higher antibiotic use among infected residents with advanced cognitive impairment is also concerning. Further efforts to understand mechanisms driving these trends and to promote antibiotic stewardship in nursing homes are warranted.

Antimicrobial use at the end of life: a scoping review

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.

Antibiotic use during end-of-life care: A systematic literature review and meta-analysis

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.

Which Nursing Home Residents With Pneumonia Are Managed On-Site and Which Are Hospitalized? Results from 2 Years' Surveillance in 14 US Homes

OBJECTIVES

Pneumonia is a frequent cause of hospitalization among nursing home (NH) residents, but little information is available as to how clinical presentation and other characteristics relate to hospitalization, and the differential use of antimicrobials based on hospitalization status. This study examined how hospitalized and nonhospitalized NH residents with pneumonia differ.

DESIGN

Data from a 2-year prospective study of residents who participated in a randomized controlled trial.

SETTING AND PARTICIPANTS

All residents from 14 NHs in North Carolina followed for pneumonia over a 2-year period.

METHODS

Clinical features, antimicrobial treatment, hospitalization, and demographic data on residents with a pneumonia diagnosis were abstracted from charts; NH information was obtained from NH administrators.

RESULTS

A total of 509 pneumonia episodes were reported for 395 unique residents; the incidence was not higher in the winter months, and 28% were hospitalized. The likelihood of hospitalization did not differ by clinical characteristics except that residents with a respiratory rate >25 breaths per minute were more likely to be hospitalized. Being on hospice [odds ratio (OR) 3.3, 95% confidence interval (CI) 1.5-7.4] and not having dementia (OR 1.9, 95% CI 1.1-3.2) also related to increased likelihood of hospitalization. Fluoroquinolone (usually levofloxacin) monotherapy was the most common treatment (54%) in both settings, and ceftriaxone monotherapy varied by hospitalization status (7% of hospitalized vs 16% treated on-site). Approximately 36% of nonhospitalized residents received antimicrobials for more than 7 days.

CONCLUSIONS/IMPLICATIONS

Respiratory rate is associated with hospitalization but was not documented for more than a quarter of residents, suggesting the clinical benefit of more consistently conducting this assessment. Differential hospitalization rates for persons with dementia and on hospice suggest that care is being tailored to individuals' wishes, but this assumption merits study, as does use of fluoroquinolones (due to side effects) and treatment duration (due to potential contribution to antibiotic resistance).

Discrepancies in preferences regarding the care of terminal-phase pneumonia in elderly patients among patients, families, and doctors: A multicenter questionnaire survey in nagasaki, Japan

BACKGROUND

Before advance care planning, it is essential to understand the differences in preferences for medical care of terminal-phase pneumonia in elderly patients among the patients, their families, and their doctors. This study aimed to clarify these differences and investigate the actual care provided to elderly patients with pneumonia in nursing hospitals.

METHODS

Multicenter questionnaire surveys of 179 patients admitted to nursing homes and long-term care beds in hospitals of three healthcare corporations, their families, and their physicians were conducted between January and August 2018. The questionnaires mainly assessed preferences for life-prolonging medical care procedures, including antibiotic treatments, in terminal-phase pneumonia. A follow-up survey regarding the prognosis and the actual care provided by the physicians was conducted 1 year after the first survey.

RESULTS

Only 16.2% of the patients had sufficient prior discussions with their families about their care. More families preferred cardiac massage, intubation, and tracheostomy, while fewer families preferred peripheral intravenous fluids or antibiotics than physicians. A total of 30 patients' families (16.7%) answered to withhold antibiotic treatment, while all physicians supported antibiotic administration. The only significant factor related to withholding antibiotics was high age (P = 0.0057). The follow-up survey administered to the doctors revealed that 49 patients (35.7%) had died within one year. Of the 137 patients, 54 patients (39.4%) had developed pneumonia during this observation period and all were treated with antibiotics.

CONCLUSIONS

This study revealed large discrepancies between patients/families and physicians regarding preferences for care. Medical staff should make efforts to fill the gap by ensuring advance care planning.

A qualitative study of nurses' perspective about the impact of end-of-life communication on the goal of end-of-life care in nursing home

BACKGROUND

With a growing nursing home population suffering from chronic progressive illnesses and evolving patterns of comorbidities, end-of-life communication takes on a critical role to enable healthcare professionals to gather information about the resident's wishes for care at the end-of-life and organise the care plan accordingly.

AIM

To explore nurses' perspective about the process by which end-of-life communication impacts on the goal of end-of-life care in nursing home residents.

DESIGN

A qualitative descriptive research design based on thematic analysis was performed. Fourteen nurses involved in the care of residents during their last week of life were recruited across 13 Italian nursing homes and accounted for 34 semi-structured interviews. A combined approach of analysis that incorporated a data-driven inductive approach and a theory-driven one was adopted.

RESULTS

Twelve themes described how end-of-life communication may contribute to adjust the care plan in nursing home according to the nurses' perspective. Five antecedents (i.e. life crisis or transitions, patient-centered environment, arising the question of possible dying, quality of relationships and culture of care) influenced the establishment and quality of communication, and five attributes depicted the characteristics and potential mechanisms of end-of-life communication (i.e. healthcare professional-resident and healthcare professional-family carers communication, knowledge of family carers' preferences, knowledge of residents' preferences, family carers and residents understanding, and shared decision-making), while curative-oriented and palliative-oriented care goals emerged as consequences.

CONCLUSION

This study provides insight into the nursing perspective of end-of-life communication between healthcare professionals and bereaved family carers of nursing home residents. Several factors influenced the occurrence and quality of end-of-life communication, which contributed to the transition towards palliative-oriented care by using and improving knowledge about family cares' and resident's preferences for end-of-life care, promoting family carers and residents understanding about prognosis and treatments available, and fostering shared decision-making.

Concept Development of Identification of Discomfort for Nursing Home Patients With Advanced Dementia

PURPOSE

The aim of this study is to clarify the concept of discomfort identification by concept development in the nursing home.

METHODS

The Schwartz-Barcott and Kim's hybrid model was used.

FINDINGS

The identification of discomfort can be explained as an interactive and confirmative process of sympathetically responding to patients with dementia's problem behavior expressions that communicate unmet needs.

CONCLUSIONS

The identification of discomfort has the potential to improve the detection of multidimensional discomfort related to nursing diagnosis as a holistic and patient-centered approach.

IMPLICATION FOR NURSING PRACTICE

The findings could help nursing home nurses have a better understanding of identification of discomfort and can improve nurses and interdisciplinary caregivers' knowledge for developing appropriate comfort caring activities.

Mechanisms by which end-of-life communication influences palliative-oriented care in nursing homes: A scoping review

OBJECTIVE

End-of-life communication has been largely recognized to promote quality end-of-life care in nursing home (NHs) by increasing residents' likelihood of receiving comfort-oriented care. This scoping review summarizes what is known about the potential mechanisms by which end-of-life communication may contribute to palliative-oriented care in NHs.

METHODS

Using the framework proposed by Arksey and O'Malley and refined by the Joanna Briggs Institute methodology, five literature databases were searched. We extracted 2159 articles, 11 of which met the inclusion criteria: seven quantitative, three qualitative, and one mixed-methods study.

RESULTS

Three mechanisms were identified: a) promotion of family carers' understanding about their family member's health condition, prognosis, and treatments available; b) fostering of shared decision-making between health care professionals (HCPs) and residents/family carers; and c) using and improving knowledge about residents' preferences.

CONCLUSION

Family carers' understanding, shared decision-making, and knowledge of residents' preferences contribute to palliative-oriented care in NHs.

PRACTICE IMPLICATIONS

Discussions about end-of-life should take place early in a resident's disease trajectory to allow time for family carers to understand the condition and participate in subsequent, mindful, shared decision-making. HCPs should conduct systematic and thorough discussions about end-of-life treatment options with all cognitively competent residents to promote informed advance directives.

Good end-of-life care in nursing home according to the family carers' perspective: A systematic review of qualitative findings

BACKGROUND

Nursing homes are becoming a common site where delivering end-of-life care for older adults. They often represent the junction between the curative and the palliative phase.

AIM

To identify the elements that nursing home residents' family carers perceive as good end-of-life care and develop a conceptual model of good end-of-life care according to the family perspective.

DESIGN

Systematic review (PROSPERO no. 95581) with meta-aggregation method.

DATA SOURCES

Five electronic databases were searched from inception between April and May 2018. Published qualitative studies (and mixed-method designs) of end-of-life care experience of nursing home family carers whose relative was dead or at the end-of-life were included. No language or temporal limits were applied.

RESULTS

In all, 18 studies met inclusion criteria. A 'life crisis' often resulted in a changed need of care, and the transition towards palliative care was sustained by a 'patient-centered environment'. Family carers described good end-of-life care as providing resident basic care and spiritual support; recognizing and treating symptoms; assuring continuity in care; respecting resident's end-of-life wishes; offering environmental, emotional and psychosocial support; keeping family informed; promoting family understanding; and establishing a partnership with family carers by involving and guiding them in a shared decision-making. These elements improved the quality of end-of-life of both residents and their family, thus suggesting a common ground between good end-of-life care and palliative care.

CONCLUSION

The findings provide a family-driven framework to guide a sensitive and compassionate transition towards palliative care in nursing home.

Current opinion about antimicrobial therapy in palliative care: an update

PURPOSE OF REVIEW

The review englobes the latest studies published regarding the problem of antimicrobial usage with palliative intent.

RECENT FINDINGS

In the advanced stages of illness like cancer, dementia, or neurodegenerative diseases, important decisions have to be made concerning the global treatment plan. Infections are very common among this kind of patients as they typically have multiple comorbidities and are incapacitated. These infections, in a majority of the cases, will be treated with antimicrobial therapy because this is a standard medical procedure. For a health professional, the decision of whether to treat, withhold, or withdraw a treatment can be difficult. In fact, in palliative care, the challenge is to balance compassionate care for people suffering from end-of-life diseases with the need for responsible antibiotic usage. Antimicrobial treatment could alleviate symptoms from an infection and make patients more comfortable, on the other hand, its overuse of it could bring a broader public health risk.

SUMMARY

On the contrary, in 18 months there are few studies about this problem, what reveals no concern about the use of antimicrobians in end-of-life patients.