Antimicrobial Use at the End of Life Among Hospitalized Patients With Advanced Cancer

Thompson, Andrew J.; Silveira, Maria J.; Vitale, Caroline A.; Malani, Preeti N.

doi:10.1177/1049909111432625

Cited by 71 publications

(84 citation statements)

References 22 publications

(38 reference statements)

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“…19,20 Other studies including patients with malignancies at the end of their life have found high rates of antibiotic use. 21 Data is limited and conflicting as to whether such treatments result in improved level of comfort. 22,23 Recently, POLST was found to lack impact on antibiotic administration in nursing home residents.…”

Section: Discussionmentioning

confidence: 99%

Advance Directives and Care Received by Older Nursing Home Residents

Manu

Mody

McNamara

et al. 2016

Am J Hosp Palliat Care

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Background Research shows variable success as to whether care provided aligns with individual patient preferences as reflected in their advance directives (AD). Objective We aimed to study AD status and subsequent care received in older nursing home (NH) residents deemed at risk for infections and care transitions: those with a urinary catheter (UC), feeding tube (FT) or both. Design/subjects/measurements A subgroup analysis of a prospective cohort of 90 residents with a UC and/or FT from 15 NHs in southeast Michigan. Outcomes assessed at enrollment and at 30-day intervals were hospitalizations and antibiotic use. ADs were divided as follows: 1) comfort-oriented: comfort measures only, no hospital transfer, 2) palliative-oriented: comfort focused, allowing hospital transfer (except ICU), antibiotic use, but no CPR, 3) usual care: full code, no limitations to care. We calculated incidences for these outcomes. Results Seventy-eight (87%) residents had ADs: 18 (23%) comfort-oriented, 32 (41%) palliative-oriented and 28 (36%) usual care. The groups did not differ regarding demographics, co-morbidity, function, device presence or time in study. Using the usual care group as comparison, the comfort-oriented group was hospitalized at a similar rate (IR= 15.6/1000 follow-up-days versus IR=8.8/1000 follow-up-days, IRR 0.6 [95% CI, 0.3, 1.1], p-value 0.09) but received fewer antibiotics (IR=18.9/1000 follow-up-days versus IR=7.5/1000 follow-up-days, IRR 0.4 [95% CI, 0.2, 0.8], p-value 0.005). Conclusion NH residents with comfort-oriented ADs were hospitalized at a rate similar to those with usual care ADs but received fewer antibiotics, although the small sample size of this analysis suggests these findings deserve further study.

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Section: Discussionmentioning

confidence: 99%

Advance Directives and Care Received by Older Nursing Home Residents

Manu

Mody

McNamara

et al. 2016

Am J Hosp Palliat Care

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“…As we discussed in that article (5), there may be less incentive for diagnostic coding beyond the primary diagnosis in hospice care because therapy is directed at symptoms, and reimbursement is fixed at a per diem rate. Furthermore, in a study of hospitalized patients with advanced cancer who ultimately died in the hospital, only approximately 70% of patients who received antimicrobial therapy met clinical criteria for an infection (12).…”

Section: Discussionmentioning

confidence: 99%

Frequency of Outpatient Antibiotic Prescription on Discharge to Hospice Care

Furuno

Noble

Horne

et al. 2014

Antimicrob Agents Chemother

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eThe use of antibiotics is common in hospice care despite limited evidence that it improves symptoms or quality of life. Patients receiving antibiotics upon discharge from a hospital may be more likely to continue use following transition to hospice care despite a shift in the goals of care. We quantified the frequency and characteristics for receiving a prescription for antibiotics on discharge from acute care to hospice care. This was a cross-sectional study among adult inpatients (>18 years old) discharged to hospice care from Oregon Health & Science University (OHSU) from 1 January 2010 to 31 December 2012. Data were collected from an electronic data repository and from the Department of Care Management. Among 62,792 discharges, 845 (1.3%) patients were discharged directly to hospice care (60.0% home and 40.0% inpatient). Most patients discharged to hospice were >65 years old (50.9%) and male (54.6%) and had stayed in the hospital for <7 days (56.6%). The prevalence of antibiotic prescription upon discharge to hospice was 21.1%. Among patients discharged with an antibiotic prescription, 70.8% had a documented infection during their index admission. Among documented infections, 40.3% were bloodstream infections, septicemia, or endocarditis, and 38.9% were pneumonia. Independent risk factors for receiving an antibiotic prescription were documented infection during the index admission (adjusted odds ratio [AOR] ‫؍‬ 7.00; 95% confidence interval [95% CI] ‫؍‬ 4.68 to 10.46), discharge to home hospice care (AOR ‫؍‬ 2.86; 95% CI ‫؍‬ 1.92 to 4.28), and having a cancer diagnosis (AOR ‫؍‬ 2.19; 95% CI ‫؍‬ 1.48 to 3.23). These data suggest that a high proportion of patients discharged from acute care to hospice care receive an antibiotic prescription upon discharge.

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“…Infections are common at the end of life. Nearly half of patients with advanced dementia, 90% of hospitalised patients with end‐stage cancer and over a quarter of patients in hospices are commenced on antimicrobials in the final 2 weeks of life . Despite the documented goal of care being to optimise symptom palliation and reduce burdensome interventions or treatments, antimicrobials are continued into the terminal phase (last few days of life) in more than one‐third of cancer patients …”

Section: Introductionmentioning

confidence: 99%

“…Nearly half of patients with advanced dementia, 90% of hospitalised patients with end-stage cancer and over a quarter of patients in hospices are commenced on antimicrobials in the final 2 weeks of life. [12][13][14] Despite the documented goal of care being to optimise symptom palliation and reduce burdensome interventions or treatments, antimicrobials are continued into the terminal phase (last few days of life) in more than one-third of cancer patients. 12 As almost three-quarters of Australian COPD patients die in hospital, 15 we hypothesised that these patients may receive more antimicrobials in a bid to preserve life, compared with those patients who survive exacerbations.…”

Section: Introductionmentioning

confidence: 99%