Antibiotics Commonly Prescribed for Hospice Patients
By Will Boggs MD
NEW YORK - About one in five patients discharged from the hospital to hospice care receives an antibiotic prescription, according to a study in Oregon.
"We recognize the extreme difficulty associated with making these decisions in hospice care," Dr. Jon P. Furuno from Oregon Health & Science University in Portland told Reuters Health by email. "That said, antibiotic prescribing and the presumed outcomes of antibiotic use should be consistent with the goals of care in hospice, specially to minimize suffering, reduce symptoms, and maximize the quality of life for patients and their loved ones."
"Thus, when deciding whether or not to prescribe antibiotics, physicians should consider both the wishes of the families, but also the probability that antibiotics may benefit the patient as well as potential harms associated with these medications," he said. "At present, there are very little data on the effectiveness and potential harms of antibiotics to assist physicians with these decisions."
Infection is prevalent and often the ultimate cause of death among hospice patients, but there is limited evidence that antibiotic use benefits hospice patients by reducing symptom burden, prolonging survival, or improving quality of life, Dr. Furuno and colleagues note.
They investigated the prevalence of and characteristics associated with receiving an outpatient antibiotic prescription on discharge to hospice care in a cross-sectional study of 67,792 adults, 845 of whom were discharged directly to hospice care during the study period.
Among these 845 patients, 178 (21.1%) received an outpatient antibiotic prescription on discharge, according to the July 7 Antimicrobial Agents and Chemotherapy online report. About 17.4% of these patients received a prescription for more than one antibiotic on discharge.
Patients discharged to hospice with antibiotic prescriptions were significantly younger than those discharged without an antibiotic prescription, and a cancer diagnosis was more common among those discharged with (65.7%) than without (55.5%) such a prescription.
Nearly three quarters of patients (71.8%) discharged with an antibiotic prescription had a documented infection during their admission. Only 11.8% of patients, though, received a prescription for intravenous antibiotics upon discharge despite the fact that many infections were considered complicated.
Factors associated with receiving an antibiotic prescription included discharge to home hospice care, the presence of a documented infection during the admission, and a cancer diagnosis. Palliative care consultation (which took place for 84% of patients) was not significantly associated with receiving an antibiotic prescription on discharge.
"We hypothesize that antibiotics may be offered more frequently to cancer patients because they recently renounced other forms of aggressive care or because clinicians may feel obligated to treat infections potentially associated with cancer chemotherapy," the researchers say.
"I am not aware of any survey data to suggest why physicians prescribe antibiotics in hospice care, although we are currently involved in a study to better understand antibiotic decision making in this setting," Dr. Furuno said. "We hypothesize that prescribing decisions, including those for antibiotics, are heavily influenced by patient and family preferences in addition to the belief that there may be benefits to the patient. Physicians may assume that antibiotics will help with symptoms or help the patient live longer, which may be true, or it may be that in many cases antibiotics do not work as well for patients who are terminally ill as they do for patients who are not."
"Physicians must recognize the shift in goals of care when patients transition to hospice and the potential for antibiotics to have harmful effects, which should be weighed in addition to the potential benefits and patient and families wishes," Dr. Furuno concluded. "Again, there are limited available data to assist with this, but antibiotics have well-described adverse effects in non-terminally ill patients, so it stands to reason these may also occur in terminally-ill patients."
Dr. Preeti N. Malani from University of Michigan Medical School in Ann Arbor has researched the use of antimicrobials among patients receiving palliative care consultations. She told Reuters Health via email, "Given significant treatment burdens, potential for adverse effects, and public health risks, antimicrobial therapy should be viewed as 'aggressive care' in the end-of-life setting, much like other measures. The potential benefits and burdens of treatment should be carefully assessed for each patient, especially when optimizing comfort is the stated goal."
"Although a 'therapeutic trial' of antimicrobial therapy is often reasonable if consistent with the preferences of the patient, this approach can distract from the overall goals of care and delay transition to hospice care," Dr. Malani said.
"If treatment is desired, I'd suggest giving oral therapy whenever possible," Dr. Malani concluded. "If prolonging survival is not a primary goal (as is the case with hospice), withholding antimicrobial agents should be considered."
SOURCE: https://bit.ly/1sZbxQj
Antimicrob Agents Chemother 2014.
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