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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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Podgorica N, Flatscher-Thöni M, Deufert D, Siebert U, Ganner M. A systematic review of ethical and legal issues in elder care. Nurs Ethics 2020; 28:895-910. [PMID: 32468910 DOI: 10.1177/0969733020921488] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Ethical and legal issues are increasingly being reported by health caregivers; however, little is known about the nature of these issues in geriatric care. These issues can improve work and care conditions in healthcare, and consequently, the health and welfare of older people. AIM This literature review aims to identify research focusing on ethical and legal issues in geriatric care, in order to give nurses and other health care workers an overview of existing grievances and possible solutions to take care of old patients in a both ethical and legally correct way. METHODS Using a systematic approach based on Aveyard, a search of the PubMed, CINAHL, and Ethicshare databases was conducted to find out the articles published on ethical and legal issues in geriatric care. ETHICAL CONSIDERATIONS The approval for the study was obtained from UMIT-The Health and Life Sciences University, Austria. RESULTS Only 50 articles were included for systematic analysis reporting ethical and legal issues in the geriatric care. The results presented in this article showed that the main ethical issues were related to the older people's autonomy, respect for their needs, wishes and values, and respect for their decision-making. The main legal issues were related to patients' rights, advance directives, elderly rights, treatment nutrition dilemma, and autonomy. CONCLUSION Further education for professional caregivers, elderly people, and their families is needed on following topics: care planning, directive and living wills, and caregiver-family member relationships to guide and support the elderly people within their decision-making processes and during the end-of-life care.
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Affiliation(s)
- Nertila Podgorica
- UMIT-University for Health Sciences, Austria; 307399FH Gesundheit-Health University of Applied Sciences Tyrol, Austria
| | | | | | - Uwe Siebert
- 31510UMIT-University for Health Sciences, Austria
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Hiemstra B, Bergman R, Absalom AR, van der Naalt J, van der Harst P, de Vos R, Nieuwland W, Nijsten MW, van der Horst ICC. Long-term outcome of elderly out-of-hospital cardiac arrest survivors as compared with their younger counterparts and the general population. Ther Adv Cardiovasc Dis 2018; 12:341-349. [PMID: 30231773 PMCID: PMC6266245 DOI: 10.1177/1753944718792420] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 06/20/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND: Over the past decade, prehospital and in-hospital treatment for out-of-hospital cardiac arrest (OHCA) has improved considerably. There are sparse data on the long-term outcome, especially in elderly patients. We studied whether elderly patients benefit to the same extent compared with younger patients and at long-term follow up as compared with the general population. METHODS: Between 2001 and 2010, data from all patients presented to our hospital after OHCA were recorded. Elderly patients (⩾75 years) were compared with younger patients. Neurological outcome was classified as cerebral performance category (CPC) at hospital discharge and long-term survival was compared with younger patients and predicted survival rates of the general population. RESULTS: Of the 810 patients admitted after OHCA, a total of 551 patients (68%) achieved return of spontaneous circulation, including 125 (23%) elderly patients with a mean age of 81 ± 5 years. In-hospital survival was lower in elderly patients compared with younger patients with rates of 33% versus 57% ( p < 0.001). A CPC of 1 was present in 73% of the elderly patients versus 86% of the younger patients ( p = 0.031). In 7.3% of the elderly patients, a CPC >2 was observed versus 2.5% of their younger counterparts ( p = 0.103). Elderly patients had a median survival of 6.5 [95% confidence interval (CI) 2.0-7.9] years compared with 7.7 (95% CI 7.5-7.9) years of the general population ( p = 0.019). CONCLUSIONS: The survival rate after OHCA in elderly patients is approximately half that of younger patients. Elderly patients who survive to discharge frequently have favorable neurological outcomes and a long-term survival that approximates that of the general population.
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Affiliation(s)
- Bart Hiemstra
- Department of Critical Care, University of
Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30.001,
Groningen, 9700 RB, The Netherlands
| | - Remco Bergman
- University of Groningen, University Medical
Center Groningen, Groningen, The Netherlands
| | - Anthony R. Absalom
- University of Groningen, University Medical
Center Groningen, Groningen, The Netherlands
| | - Joukje van der Naalt
- University of Groningen, University Medical
Center Groningen, Groningen, The Netherlands
| | - Pim van der Harst
- University of Groningen, University Medical
Center Groningen, Groningen, The Netherlands
| | - Ronald de Vos
- University of Groningen, University Medical
Center Groningen, Groningen, The Netherlands
| | - Wybe Nieuwland
- University of Groningen, University Medical
Center Groningen, Groningen, The Netherlands
| | - Maarten W. Nijsten
- University of Groningen, University Medical
Center Groningen, Groningen, The Netherlands
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Sourdet S, Rochette C, de Souto Barreto P, Nourhashemi F, Piau A, Vellas B, Rolland Y. Drug Prescriptions in Nursing Home Residents during their Last 6 Months of Life: Data from the IQUARE Study. J Nutr Health Aging 2018; 22:904-910. [PMID: 30272091 DOI: 10.1007/s12603-018-1071-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To assess the drug prescriptions of nursing home (NH) residents during the 6 months prior to their death, and the impact of the recognition of « life expectancy lower than 6 months » by the NH staff on the prescriptions. DESIGN Prospective study. SETTING 175 nursing homes in France. PARTICIPANTS 6275 residents were included from May to June 2011. MEASUREMENTS The initial drug prescriptions of the residents who deceased within 6 months were compared with those who did not decease. Among the residents deceased within 6 months, the drug prescriptions were compared between the residents who were «considered at the end of their life» and those who were not. Potentially inappropriate prescriptions (PIP) were analyzed using Laroche criteria and a list of therapies considered as inappropriate at the end of life. RESULTS 498 residents (7.9%) died within 6 months after their inclusion: they had significantly more therapies (8.3 ± 3.8 vs. 7.9 ± 3.5, p=0.048) than non-deceased people. Sixty-one of the residents deceased within 6 months were considered by the NH staff as «end of life residents » (12.2%). They received significantly less drugs (6.4 ± 4.2 vs 8.5 ± 3.6, p<0.001) than NH's residents not identified at the end of their life. They had a more frequent prescription of opioids (p<0.001), and less antipsychotics (p<0.001), lipid-lowering drugs (p=0.006), or antihypertensive therapies (p<0.01). They also received significantly less PIP (59.0% received at least one inappropriate prescription, vs. 87.2%, p<0.001). CONCLUSION An important proportion of nursing home residents received PIP. The quality of prescriptions in patients identified at the end of their life seems to improve, but more than half still receive inappropriate drugs. Special attention in prescribing should be given to these patients presenting a high risk of adverse events.
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Affiliation(s)
- S Sourdet
- S Sourdet, Centre Hospitalier Universitaire de Toulouse, France,
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Age-based disparities in end-of-life decisions in Belgium: a population-based death certificate survey. BMC Public Health 2012; 12:447. [PMID: 22708727 PMCID: PMC3489592 DOI: 10.1186/1471-2458-12-447] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 04/12/2012] [Indexed: 11/17/2022] Open
Abstract
Background A growing body of scientific research is suggesting that end-of-life care and decision making may differ between age groups and that elderly patients may be the most vulnerable to exclusion of due care at the end of life. This study investigates age-related disparities in the rate of end-of-life decisions with a possible or certain life shortening effect (ELDs) and in the preceding decision making process in Flanders, Belgium in 2007, where euthanasia was legalised in 2002. Comparing with data from an identical survey in 1998 we also study the plausibility of the ‘slippery slope’ hypothesis which predicts a rise in the rate of administration of life ending drugs without patient request, especially among elderly patients, in countries where euthanasia is legal. Method We performed a post-mortem survey among physicians certifying a large representative sample (n = 6927) of death certificates in 2007, identical to a 1998 survey. Response rate was 58.4%. Results While the rates of non-treatment decisions (NTD) and administration of life ending drugs without explicit request (LAWER) did not differ between age groups, the use of intensified alleviation of pain and symptoms (APS) and euthanasia/assisted suicide (EAS), as well as the proportion of euthanasia requests granted, was bivariately and negatively associated with patient age. Multivariate analysis showed no significant effects of age on ELD rates. Older patients were less often included in decision making for APS and more often deemed lacking in capacity than were younger patients. Comparison with 1998 showed a decrease in the rate of LAWER in all age groups except in the 80+ age group where the rate was stagnant. Conclusion Age is not a determining factor in the rate of end-of-life decisions, but is in decision making as patient inclusion rates decrease with old age. Our results suggest there is a need to focus advance care planning initiatives on elderly patients. The slippery slope hypothesis cannot be confirmed either in general or among older people, as since the euthanasia law fewer LAWER cases were found.
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Abstract
Considerable controversy surrounds the issue of care at the end of life (EOL) for older adults. Technological advances and the legal, ethical, clinical, religious, cultural, personal, and fiscal considerations in the provision of artificial hydration and nutrition support to older adults near death are presented in this comprehensive review.
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Affiliation(s)
- Roschelle A Heuberger
- Department of Human Environmental Studies, Central Michigan University, Mt. Pleasant, Michigan 48859, USA.
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Suhonen R, Stolt M, Launis V, Leino-Kilpi H. Research on ethics in nursing care for older people: A literature review. Nurs Ethics 2010; 17:337-52. [DOI: 10.1177/0969733010361445] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this review was to analyse the empirical studies that focus on ethics in nursing care for older people, scoping the need and areas for further study. A search of the MEDLINE and CINAHL databases (earliest to August 2009) was conducted using the the keywords: ethic* and nursing or care or caring and elderly or aged or older. After a four-stage process, 71 empirical articles were included in the review, with informants ranging from elderly people to relatives, caregivers, managers and students in care settings. The review focusses on the concepts, contexts, methods and validity of these studies. Based on the analysis, the reviewed research seems to be fragmented and multifaceted, focussing on selected issues such as autonomy, self-determination and informed consent. No large research programs or research traditions were found so it was not possible to draw any conclusions about suitable methods, study designs or instruments of measurement for use in this research area.
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Affiliation(s)
| | | | | | - Helena Leino-Kilpi
- University of Turku, Turku, Finland & Hospital District of South-Western Finland
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Eachempati SR, Hydo L, Shou J, Barie PS. Sex differences in creation of do-not-resuscitate orders for critically ill elderly patients following emergency surgery. ACTA ACUST UNITED AC 2006; 60:193-7; discussion 197-8. [PMID: 16456455 DOI: 10.1097/01.ta.0000197683.89002.62] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Emergency surgery patients are older, often critically ill, and at high risk of morbidity and mortality. We studied factors associated with issuance of a do-not-resuscitate (DNR) order and impact on morbidity and mortality in emergency surgery patients. METHODS Prospective study of all patients since January 1, 2000 who underwent emergency surgery before admission to the intensive care unit. Data collected were: age, sex, admission diagnosis (case-mix), raw- (AIII) and age-adjusted (aAIII) APACHE III scores, issuance of a DNR order, and morbidity and mortality. Primary outcomes were DNR status and morbidity and mortality. Groups were stratified by age (patients >75 years versus younger) and sex. Statistics were calculated by chi(2) test, analysis of variance, and logistic regression. RESULTS In all, 723 emergency surgery patients (gastrointestinal: 35%; traumatic: 20%; neurologic: 17%) met study criteria and had morbidity and mortality of 17.8% (AIII-predicted: 31%). Ninety-two patients (12%) were made DNR, of whom 82.6% died. Women received DNR status more often (16.4% versus 9.5%, p < 0.01) but morbidity and mortality was the same for women and men (18.2% versus 17.5%, p = 0.85). By logistic regression, sex most predicted new DNR status (odds ratio [OR] 2.512, p = 0.005) compared with Multiple Organ Dysfunction score (OR 1.410, p < 0.0001), Age (OR 1.054, p < 0.0001) and aAIII (OR 0.995, 0.355), with goodness of fit of 3.876 (p = 0.868) and Nagelkerke R(2) of 0.511. Percent correct was 88.9, implying good discrimination. CONCLUSIONS Female sex and, to a lesser extent, age were associated with issuance of DNR in series of patients who received emergency surgery. The association of DNR with female sex is an unexpected finding and may indicate clinician bias and necessitate the performance of further analysis.
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Affiliation(s)
- Soumitra R Eachempati
- Department of Surgery, Weill Medical College, Cornell University, 515 East 68th Street, New York, NY 10021, USA.
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Mpinga EK, Chastonay P, Rapin CH. Conflits et fin de vie dans le contexte des soins palliatifs : une revue systématique de littérature. Rech Soins Infirm 2006. [DOI: 10.3917/rsi.086.0068] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Brandsen CK. Social work and end-of-life care: reviewing the past and moving forward. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2005; 1:45-70. [PMID: 17387063 DOI: 10.1300/j457v01n02_05] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
This paper reviews the professional literature with respect to the social work profession's involvement in end-of-life care. The search process was conducted by entering key words in various combinations to electronic databases. Eligible articles were required to address one of the following: roles and activities of social workers in providing end-of-life care; core principles valued by social workers in the provision of end-of-life care; and barriers to provision of effective end-of-life care. The literature from 1990 through July 2004 was searched most rigorously. Based on this review, suggestions for where the profession of social work should focus its energies are offered. These key areas include focusing on generating empirically-based knowledge for practice and policy analysis and developing a system of social work education that addresses the unique knowledge and skills needed to participate in end-of-life practice as competent and informed professional practitioners. Current initiatives with regard to critical areas are summarized.
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Affiliation(s)
- Cheryl K Brandsen
- Department of Sociology and Social Work, Calvin College, 3201 Burton SE, Grand Rapids, MI, USA
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