1)The Archives of Internal Medicine published a significant study regarding antibiotic use in the elderly authored by Dr. D'Agata and Dr. Mitchell from Beth Israel Deaconess. In their article, they review the antibiotic usage in 214 (mostly white, female and over 80yo) nursing home residents with advanced dementia, defined as very severe cognitive impairment, minimal communication, dependent eating/toileting, bowel/bladder incontinence, and inability to walk. This study was part of a larger study called CASCADE (Choices, Attitudes and Strategies for Care of Advanced Dementia at the End-of-Life). (Take that cardiologists with all your fancy acronyms!)
The mean number of antibiotic courses per resident was 4 (range 1-20!), and about 66% of the 214 received at least one course with the majority of residents receiving a course within the 14 days prior to death, indicating the effectiveness of antibiotics to cure an infection in advanced dementia may be limited. This multi-center prospective cohort is probably the best study to demonstrate the limited efficacy of antibiotics in patients with advanced dementia.The study did not have data representing success of treatment for each course, which makes hampers clinical relevance. If we had information that indicated say 80% of the UTI's were cured, but only 35% of respiratory infections improved or similar info, we could have more informed discussions with staff and family. Also this article does not have information on symptom improvement, since antibiotics may have improved symptoms (although data in elderly says this is not a major effect), but that would be difficult to get workable objective data from someone who by inclusion criteria cannot communicate.
Despite this information, one cannot conclusively make an across the board declaration that patients with advanced dementia should never get antibiotics. We don't yet know what the outcomes might be for those that had antibiotics withheld. There is a general understanding that fever and likely infections are a common pathway towards death for advanced dementia patients. The optimal strategy is not yet clear, and these issues must be decided on an individual basis with open discussions of goals of care. But this study may help nursing home staff, and hospice and palliative medicine staff make more judicious use of a minimally efficacious treatment, that as a secondary gain could potentially help public health by decreasing antibiotic resistance in the community. I would imagine this second point is a bit more challenging to ethically justify. Autonomy versus Distributive Justice...en garde!
Interestingly the CDC is debating on how to advocate influenza immunization of all school age children to protect the children, but also to decrease influenza deaths/infections in the older community. The CDC are not necessarily advocating we "treat the children to save the elderly." So it is interesting this Archives of Internal Medicine study could be spun as "Don't treat the elderly to save the children." I realize I am making broad generalizations, but it is interesting the eerie similarities between the two circumstances. The editorial for this article is highly recommended as well.
(Thanks to Pallimed reader Maria F for the tip!)
D'Agata, E., Mitchell, S.L. (2008). Patterns of Antimicrobial Use Among Nursing Home Residents With Advanced Dementia. Archives of Internal Medicine, 168(4), 357-362. DOI: 10.1001/archinternmed.2007.104
I have had so many things crossing my desk that I have wanted to share, that I have to clear some of these out.For our chaplain readers, you may be interested in the recent Religious Landscape Survey by the Pew Forum on Religion and Public Life. The site has some good demographic maps to look at the different faith communities in the US and by states. The full report is here. The media's take on this has been focused on how people change religions more often.
The British Medical Journal recently published a clinical review on treatment of adult depression. Dr. Shock (a blogger) reviews it nicely. Obviously the article is not focused on palliative medicine, but a good general background on current views on depression management (and not just pharmacological management). But before you prescribe that Prozac, a recent study (free pdf) in PLoS Medicine suggests that antidepressants may be no better than placebo. James Hrynyshyn at Island of Doubt has a nice blog post summarizing the study and the drug-placebo controversy.
Thomas LeBlanc and Amy Abernathy (of PC-FACS) explore research in hospice patients in an ethics forum for American Medical News. A good conversational review on a desperately needed area.
And finally with the recent movie "The Bucket List" about making a list of things to do before you die comes this very helpful blog post about priorities in life and how to 'manage' your bucket list.
8 comments:
As a hospitalist, I am constantly seeing these white, over 80 LOL's with cognitive inpairment sent to hospital for treatment- I read this study and wondered why nursing home Docs do not make the argument more frequently, that hospitalization, and antibiotics are of marginal benefit-This study suggests to me that this is so, and we ought to consider not using them.
I was talking with a geriatrician the other day about this study, and an important point came up. The many factors that lead to sending someone to the ER/hospital from a nursing home have yet to be fully understood. Issues like a different on-call doctor who doesn't know the patient or family well, or the frequent staff turnover seen in some nursing homes, where the nursing staff can't advocate for the patient since they do not know them as well. Or the patient to nursing ratio that prevents an overworked nursing staff to attend appropriately to a sick and possibly dying patient. Or the fact that there may be a number of patients at nursing homes that are not sent to the ER/hospital and no one ever calls the nursing home to thank them for the patients they did not send.
Overall this study is one part of a complex system based issue. I agree this study does begin to illuminate what is effective and what is not so we can being to have more rational conversations about treatment.
POLST might be one part of the solution for the above, but it is slow to be implemented.
I came across this blog post while trying to find out how common it is to give antibiotics to very elderly people. My mother is ninety four. She has been gradually over the last year becoming more and more confused. With this last infection she really has lost cognitive function, she is unable to speak or express herself. She cannot say where she hurts or what she wants and she sees and hears things. She is currently in hospital on an I.V. drip which does not seem to be doing much to improve things. Not using the antibiotics was never discussed with me. I am beginning to wonder what exactly it is we are prolonging here? Her life? Or her death. She seems utterly miserable to me. She no longer eats except for a few sips of liquid a day. The doctors and nurses seem so intent on continuing this course. If I believed for one second as I once did that she would recover and go back to being able to carry on conversation, to be independent, to be as she would wish to be, then I would have full faith in what we are doing.
I feel the doctor is simply following some protocols that are "routine" I am put off to bring up the issue. When oh when, is it time to make her comfortable and to not keep on with this? This is one of multiple infections over the last few years. This is the worst of them all as she has lost all ability to communicate and after four and half days of strong antibiotics on an I.V. drip, no improvement. Her lungs were beginning to fill up due to the fluids given to her for dehydration, her kidneys were not putting out the level of fluids they should. More drugs are being given to try to keep the fluid off her lungs, while trying to keep her hydrated.
There is nothing left that she can enjoy in any of her waking moments now. Maybe, she will get better physically for a time but, it seems it will be expected that she is to live without knowledge of her surroundings only to end up being back at this place soon in the future. I am so torn. I do not know if we are making her better or making her suffer more in our selfishness to see her life continue no matter in what form??
Thank you for delving into this subject a bit...options are given for a D.N.R. and she has one..and I was asked what we should do if her blood pressure suddenly dropped and i said she did not want extraordinary measures...but, what ARE we doing now?? Is this a sane, and compassionate thing to do to a ninety four year old woman who would be mortified to not be able to be in control of her own life and care?? She was a nurse btw.. I know this is not somehow the right thing and yet because it's "only" antibiotics, I do not feel right stopping it unless it is an option families and patients are given! They seem so intent to do this...I am so unsure this is the right thing at this point.
Thanks for your comment Anon. While we cannot give specific medical advice on this blog there are some things to consider.
If your local hospital has a palliative care service that may be a good first step to help sort out the goals of care for your mother.
If one is not available, just asking about the goals of care is a reasonable question from families. Sometimes the medical staff may be waiting for the patient or family to bring it up. Since neither patient/family nor medical staff talk about the overall prognosis or goals of therapy everyone presumes full steam ahead.
Thanks for leaving your comment. it is good to hear the family perspective here.
Thank you for the response. A social worker is coming in to discuss things this week with the entire family. As this usually goes those who live many miles away are want to go to any length possible including feeding tubes etc. I am of the opposite opinion seeing this every day as I do and having been a primary care giver for more than one family member in the past. I've been on this path more than once.
Her breathing is very labored. There is no communication and her kidneys aren't functioning well.
A very frank discussion with all family members will need to take place. After all my angst yesterday staff approached me today to discuss options. Thank goodness!
I do think the best thing is to go with each individual situation. I have quickly learned though that I never want to be rescued in her condition with antibiotics. Just let me go comfortably and with ease when the time comes! This information on this blog is very helpful. It has let me know there are question marks on both sides of the care equation.
I am a daughter and a POA of a mother who was diagnosed with high risk myledysplasia in August at 85. She was a "young" 85 year old who was very active traveling,volunteering, gardening, reading and writing. She "failed" the only chemotheraputic agent and has had multiple infections. She has been given the choice of supportive care or hospice. She chose supportive care for blood transfusions and antibiotics. I called several hospices to see if Medicare would cover these and was told "no" as they are considered "aggressive care". However, right now she is suffering terribly from frequent neutropenic fevers and weakness due to anemia. How is this comfort?? She and we know there is no cure for her MDS, we just want her in her own home and be allowed IV antibiotics and maybe a outpatient admission once in awhile for several units of blood for comfort only. I am an APRN and live in the Chicagoland area and can not find help. I have called several hospices who offer "palliative care" but they really dont nor can tell me if Medicare and her BC/BC supplemental covers this as well. I think there is definitely "psychological distress" due to infection and I do not agree that it provides comfort to an individual to withhold blood and IV antibiotics just because they have a terminal illness. It is frustrating my whole family and my Mom, who is very alert, orientated and exhausted. Thanks for listening
Anon Mar 2010,
While we cannot give specific medical advice here, your situation is a challenging one. Nothin in the Medicare guidelines say antibiotics or transfusions are or are not covered. And they could be palliative (treating symptoms) and/or curative as well and a lot of that depends on the viewpoint. Palliative home health care teams or a open access hospice could likely do these things, but that is also up to the individual company. Sometimes talking to the medical director directly or your mother's primary doctor about your concerns may help clarify the best course.
Best wishes to you and your mother.
My grandmother is 96 and in a nursing home. Some days she is mentally present. However most days she has cognitive impairment and has a very hard time speaking and getting words out. Or understanding what I am saying. Even on good days she does have short term meory lost but not all the time. Her physical conditon is detorating. And she has now experience more incontinance and seems very depressed and fearful. My sister and I decided to change her directive advance to not having any measures taken including not using antibiotics to treat anything.
I talked with the nurse practioner and hospice is coming to talk to my grandmother and I talked with them. But I feel I am kiliing her which I will be if she does not have antibiotics. she has been getting many uti's. I feel I need to talk to my grandmother when she is mentally present and ask her what she wants. I feel we are doing this too soon. My sister who is a nurse says she will suffer and be in a lot of pain if we do this. I am confused. I love my Grandmother so much and Have been her major support and caregiver for many years. Thanks
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