Physician Perceptions Regarding Antimicrobial Use in End-of-Life Care

2018 ◽  
Vol 39 (4) ◽  
pp. 383-390 ◽  
Author(s):  
Christopher E. Gaw ◽  
Keith W. Hamilton ◽  
Jeffrey S. Gerber ◽  
Julia E. Szymczak
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
Antimicrobial Stewardship ◽  
Patient Population ◽  
Improve Patient Care ◽  
Antimicrobial Treatment ◽  
Free Text ◽  
Antimicrobial Use ◽  
Physician Decision Making ◽  
Patient Pain

BACKGROUNDThe decision to utilize antimicrobials in end-of-life situations is complex. Understanding the reasons why physicians prescribe antimicrobials in this patient population is important for informing the design of antimicrobial stewardship interventions.METHODSA 51-item survey containing both closed and open-ended questions on end-of-life antimicrobial use was administered to physicians affiliated with the University of Pennsylvania and Children’s Hospital of Philadelphia from January through April 2017. A mixed-methods approach was used to analyze responses.RESULTSOf 637 physicians surveyed, 283 responses (44.4%) were received. Most (86.2%) physicians believed that respecting a patient’s wish to continue antimicrobials was important. Approximately half of physicians (49.8%) believed that antimicrobial use at the end of life contributes to resistance. A higher proportion of pediatricians would often or always continue antimicrobial treatment for active infections and for hospice patients whose death was imminent compared to adult physicians (P<.001). Analysis of free-text responses revealed additional reasons why physicians may continue antimicrobials at end of life, including meeting family expectations, wanting to avoid the perception of “giving up,” uncertainty about prognosis, and reducing patient pain or discomfort.CONCLUSIONSPhysician decision making concerning antimicrobial use in patients at the end of life is multifactorial. Clinicians may overweigh the benefits of antimicrobial therapy in end-of-life situations and view the importance of adhering to stewardship policies differently. Pediatric and adult clinicians have different approaches to this patient population. Better understanding of the complex decision making that occurs in the end-of-life patient population can help guide antimicrobial stewardship policies and improve patient care.Infect Control Hosp Epidemiol 2018;39:383–390

scholarly journals Impact of a comprehensive antimicrobial stewardship program on antimicrobial utilization and clinical isolates distribution in ICUs

2020 ◽  
Author(s):  
Jiaojiao Song ◽  
Rongsheng Zhu ◽  
Leiqing Li ◽  
Lingcheng Xu ◽  
Quan Zhou ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Broad Spectrum ◽  
Second Generation ◽  
Antimicrobial Treatment ◽  
Clinical Isolates ◽  
Antimicrobial Use ◽  
Antimicrobial Stewardship Program ◽  
Stewardship Program ◽  
Antimicrobial Utilization ◽  
Lactamase Inhibitor

Abstract Objective This study aimed to evaluate the effect of a comprehensive antimicrobial stewardship program (ASP) and provide clinical evidence for the scientific stewardship of antimicrobials in intensive care units (ICUs) of a teaching hospital.Methods Between January 2013 and December 2018, we conducted a prospective study, based on an antimicrobial computerized clinical decision support system (aCDSS) deployed in 2015 in ICUs of a tertiary and teaching hospital. The primary outcomes included initial and overall use prevalence of antimicrobials. The second outcomes were the detection rate of common clinical isolates before and after therapeutic antimicrobial use, and the change in patterns of resistance of 5 common clinical isolates in the ICU.Results Various types of broad-spectrum antimicrobial use prevalence continued to increase from 2013 to 2015, since 2016, where initial use of carbapenems and glycopeptides were counterbalanced by an increase in use of the first/second-generation cephalosporins, β-lactam and β-lactamase inhibitor combinations and linezolid. From 2015 to 2018, the proportion of extended-broad spectrum antimicrobials alone, wide-coverage therapy and combination therapy decreased significantly (P<0.05). Similarly, where use of carbapenems, glycopeptides, third/fourth-generation cephalosporins and anti-fungi agents were counterbalanced by an increase in overall use of the first/second-generation cephalosporins and β-lactam and β-lactamase inhibitor combinations. A total of 21891 strains of bacteria and fungi were detected in ICUs from 2015 to 2018, of them, 6.5% (1426/21891) strains were detected before antimicrobial treatment. The detection proportion of Staphylococcus aureus , Escherichia coli , Klebsiella pneumoniae and fastidious bacteria were significantly higher before antimicrobial treatment (P<0.05), while Acinetobacter baumannii , Burkholderia cepacia , and Candida spp were significantly lower in all non-repetitive clinical isolates (P<0.05).Conclusions The implementation of a comprehensive ASP combining CDSS in ICUs seems to be effective to improve outcomes on antimicrobial utilization and clinical isolates distribution in critically ill patients.

Assessment of factors that influence physician decision making regarding medication use in patients with dementia at the end of life

2013 ◽  
Vol 29 (3) ◽  
pp. 281-290 ◽  
Author(s):  
Carole Parsons ◽  
Noleen McCorry ◽  
Kevin Murphy ◽  
Stephen Byrne ◽  
David O'Sullivan ◽  
...  
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
Medication Use ◽  
Physician Decision Making

Evaluation of an Antimicrobial Stewardship Approach to Minimize Overuse of Antibiotics in Patients with Asymptomatic Bacteriuria

2014 ◽  
Vol 35 (2) ◽  
pp. 193-195 ◽  
Author(s):  
Denise Kelley ◽  
Patrick Aaronson ◽  
Elaine Poon ◽  
Yvette S. McCarter ◽  
Ben Bato ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Medical Center ◽  
Academic Medical Center ◽  
Asymptomatic Bacteriuria ◽  
Antimicrobial Treatment ◽  
Antimicrobial Use ◽  
Educational Initiative ◽  
Educational Initiatives ◽  
Academic Medical ◽  
Inappropriate Treatment

An antimicrobial stewardship educational initiative provided to physicians and pharmacists was evaluated at an academic medical center to minimize inappropriate treatment of asymptomatic bacteriuria (ASB). A significant decrease in empirical antimicrobial use for ASB was observed after education. Multifaceted educational initiatives can reduce inappropriate antimicrobial treatment of ASB.

Negotiating Transitions: Involvement of Critical Care Outreach Teams in End-of-Life Decision Making

2015 ◽  
Vol 24 (3) ◽  
pp. 232-240 ◽  
Author(s):  
Natalie Pattison ◽  
Geraldine O’Gara ◽  
Timothy Wigmore
Keyword(s):  
Decision Making ◽  
Critical Care ◽  
Medical Treatment ◽  
End Of Life ◽  
End Of Life Care ◽  
Free Text ◽  
Life Care ◽  
End Of Life Decision ◽  
Life Decision ◽  
Critical Care Outreach

Background Little research has examined the involvement of critical care outreach teams in end-of-life decision making. Objective To establish how much time critical care outreach teams spend with patients who are subsequently subject to limitation of medical treatment and end-of-life decisions and how much influence the teams have on those decisions. Methods A single-center retrospective review, with qualitative analysis, in a large cancer center. Data from all patients referred emergently for critical care outreach from October 2010 to October 2011 who later had limitation of medical treatment or end-of-life care were retrieved. Findings were analyzed by using SPSS 19 and qualitative free-text analysis. Results Of 890 patients referred for critical care outreach from October 2010 to October 2011, 377 were referred as an emergency; 108 of those had limitation of medical treatment and were included in the review. Thirty-five patients (32.4%) died while hospitalized. As a result of outreach intervention and a decision to limit medical treatment, 56 (51.9%) of the 108 patients received a formal end-of-life care plan (including care pathways, referral to palliative care team, hospice). About a fifth (21.5%) of clinical contact time is being spent on patients who subsequently are subject to limitation of medical treatment. Qualitative document analysis showed 5 emerging themes: difficulty of discussions about not attempting cardiopulmonary resuscitation, complexities in coordinating multiple teams, delays in referral and decision making, decision reversals and opaque decision making, and technical versus ethical imperatives. Conclusion A considerable amount of time is being spent on these emergency referrals, and decisions to limit medical treatment are common. The appropriateness of escalation of levels of care is often not questioned until patients become critically or acutely unwell, and outreach teams subsequently intervene.

scholarly journals Antimicrobial Management of Respiratory Infections in Severe Acute Respiratory Syndrome Coronavirus 2 Patients: Clinical and Antimicrobial Stewardship Programs Conundrums

2020 ◽  
Vol 7 (11) ◽  
Author(s):  
Ellie J C Goldstein ◽  
Glenn Tillotson ◽  
Mark Redell
Keyword(s):  
Severe Acute Respiratory Syndrome ◽  
Antimicrobial Stewardship ◽  
Respiratory Infections ◽  
Antimicrobial Treatment ◽  
Current Data ◽  
Antimicrobial Use ◽  
Appropriate Treatment ◽  
Antimicrobial Management ◽  
Review Current

Abstract The role of empirical and even directed antimicrobial management of patients hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is problematic; antibiotics are used frequently among these patients to treat confirmed or suspected coinfection or just the symptoms. In the rapidly changing clinical landscape of SARS-CoV-2, there is minimal guidance for selecting appropriate treatment versus non-antimicrobial treatment, and clinicians are pressed to make daily decisions under the stress of absence of data while watching patients deteriorate. We review current data and patterns of antimicrobial use and the potential approach for antimicrobial stewardship in the context of SARS-CoV-2.

Antimicrobial prescribing in patients with advanced-stage illness in the antimicrobial stewardship era

2018 ◽  
Vol 39 (9) ◽  
pp. 1023-1029 ◽  
Author(s):  
Yasuaki Tagashira ◽  
Kanae Kawahara ◽  
Akane Takamatsu ◽  
Hitoshi Honda
Keyword(s):  
End Of Life ◽  
Antimicrobial Stewardship ◽  
Symptom Relief ◽  
Terminally Ill ◽  
Study Cohort ◽  
Antimicrobial Use ◽  
Advanced Stage ◽  
Factors Associated ◽  
Terminally Ill Patients ◽  
Days Of Therapy

AbstractObjectiveAntimicrobials are frequently administered to patients with an advanced-stage illness. Understanding the current practice of antimicrobial use at the end of life and the factors influencing physicians’ prescribing behavior is necessary to develop an effective antimicrobial stewardship program and to provide optimal end-of-life care for terminally ill patients.DesignA 1-year retrospective cohort study.SettingA public tertiary-care center.PatientsThe study included 260 adult patients who were hospitalized and later died at the study institution with an advanced-stage illness.ResultsOf 260 patients in our study cohort, 192 (73.8%) had an advanced-stage malignancy and 136 (52.3%) received antimicrobial therapy in the last 14 days of their life; of the latter, 60 (44.1%) received antimicrobials for symptom relief. Overall antimicrobial use in the last 14 days of life was 421.9 days of therapy per 1,000 patient days. Factors associated with antimicrobial use in this period included a history of antimicrobial use prior to the last 14 days of life during index hospitalization (adjusted odds ratio [aOR], 4.86; 95% confidence interval [CI], 2.67–8.84) and antipyretic use in the last 14 days of life (aOR, 4.19; 95% CI, 2.01–8.71).ConclusionApproximately half of the patients hospitalized with an advanced-stage illness received antimicrobials in the last 14 days of life. The factors associated with antimicrobial use at the end of life in this study are likely to explain physicians’ prescribing behaviors. In the current era of antimicrobial stewardship, reconsidering antimicrobial use in terminally ill patients is necessary.

scholarly journals Exploring New Zealand Paramedic Attitudes Towards Advance Directives: An Ethical Analysis

2016 ◽  
Vol 13 (4) ◽  
Author(s):  
Paul J Davey ◽  
Amanda B Lees ◽  
Rosemary Godbold
Keyword(s):  
Decision Making ◽  
New Zealand ◽  
End Of Life ◽  
Advance Directives ◽  
Professional Education ◽  
Ethical Decision Making ◽  
Ethical Issues ◽  
Care Practice ◽  
Free Text ◽  
Advanced Directives

IntroductionAdvance directives are known to present challenging ethical issues in health care practice, however there is a paucity of research paramedic perspectives. When a cardiac arrest occurs in the community, end of life provisions have often not been considered by patients or the patients are unable to communicate their wishes and these are not usually known to the attending paramedic crew. These factors contribute to an ethically complex decision-making environment. Ethical deliberation contributes to practitioners’ critical thinking skills and helps prepare them for decision-making under uncertainty. This research aims to highlight and explore underlying values present within practice-based decisions.MethodsAn exploratory, interpretive study, using the Values Exchange, a web-based ethical decision-making tool, explored eighteen urban-based New Zealand paramedics’ deliberative perspectives on an ethically controversial end of life scenario.ResultsThematic analysis of participants’ free text responses ascertained the breadth of views on advanced directives, with the emergence of three dominant themes; legal tensions, multiple constructs of dignity and seeking solutions that support clinical practice.ConclusionFindings revealed that when considering situations involving advance directives, participants regarded the duty to uphold patient dignity as paramount. There was a desire for greater legal guidance and a call for increased professional education in law and ethics. This study provides insight into New Zealand urban-based paramedics’ views and experiences of this ethically challenging aspect of patient care.

scholarly journals 160. A Pre- and Post-intervention Study to Implement a Successful Antimicrobial Stewardship Program in Palliative Care

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S89-S90
Author(s):  
James A McCracken ◽  
Mohamed Nakeshbandi ◽  
Carline Sainvil ◽  
Eduard Porosnicu ◽  
Roopali Sharma
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Antimicrobial Stewardship ◽  
Adverse Drug Events ◽  
Acceptance Rate ◽  
Small Sample ◽  
Patient Specific ◽  
Antimicrobial Use ◽  
Antimicrobial Usage ◽  
Stewardship Program

Abstract Background In patients receiving palliative care, medical interventions are transitioned away from aggressive and curative attempts to less invasive and more comfort measures. Antimicrobial usage remains a challenging subject in palliative care decisions, where many physicians focus interventions on reduction of patient pain and discomfort, without consideration for adverse effects such as the development of antimicrobial resistance or patient-specific adverse drug events. With limited data on the comfort benefit, we aimed to assess antimicrobial use in patients at the end of life in our institution as well as the success of targeted stewardship interventions in palliative care patients. Methods Patients who expired between November 2018 and August 2019 were assessed retrospectively for antimicrobial use during their last 14 days of life. In January 2020, a prospective stewardship initiative began in collaboration with our institution’s palliative care team to focus antimicrobial interventions on patients involved in goals of care discussions. Results In our retrospective review of 200 patients, 139 (69.5%) of patients received antimicrobials in their last two weeks of life, with 50% having formal palliative care consultations. The most commonly used antimicrobials were piperacillin-tazobactam (64.7%) and vancomycin (60.4%), with primary indications being pneumonia (34.5%) and empiric coverage/sepsis (24.5%). Of note, 46% of antimicrobial regimens were eligible for optimization through stewardship initiatives. From January through February 2020, sixteen stewardship interventions were made on thirteen palliative care patients, with an 81.3% acceptance rate. Duration of therapy based on indication and discontinuation of antibiotics following transition to comfort measures only were the most frequent interventions made. Table 1. Baseline Characteristics Table 2. Antimicrobial Usage - Pre-intervention Table 3. Prospective Intervention Data Conclusion Close of half of patients receiving antimicrobials at the end of life are eligible for interventions to improve antibiotic regimens. These patients are often overlooked in antimicrobial stewardship, and, despite small sample size, our study shows the benefit of targeted stewardship in palliative care populations with an intervention acceptance rate of over 80%. Disclosures All Authors: No reported disclosures

41 ‘We should not shy away from asking what it is that patients want’ a supplementary qualitative analysis of the jla peolcpsp free text data

2018 ◽  
Vol 8 (3) ◽  
pp. 375.1-375
Author(s):  
S Sivell ◽  
J Baillie ◽  
J VanGodwin ◽  
A Byrne ◽  
A Nelson
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
Priority Setting ◽  
End Of Life Care ◽  
Support Needs ◽  
Free Text ◽  
List Type ◽  
Life Care ◽  
Text Data ◽  
Priority Setting Partnership

IntroductionPalliative and end-of-life care is under-researched (Higginson 2016) with stakeholders likely to have a range of unmet communication information and support needs. The James Lind Alliance (JLA) Priority Setting Partnership (PeolcPSP) identified the pertinent ‘treatment uncertainties’ for palliative and end-of-life care focusing on interventional based research (JLA PeolcPSP Survey 2015). Respondents also submitted comments that were out of scope of the JLA methodology.AimTo undertake a supplementary analysis of JLA PeolcPSP survey free text data focusing on communication information and support needs.MethodsA supplementary thematic qualitative analysis of the JLA PeolcPSP free-text data was undertaken in the final dataset of 1403 responses. The original coding framework was reviewed and refined until agreement was reached (Nelson 2016).ResultsApproximately one third of respondents (n=444; 31.65%) were included in this analysis; four overarching themes were identified:Availability accessibility and improving information: focusing on support and guidance as well as improving and finding information.Effectiveness of communication between stakeholders: openness and transparency between stakeholders; improving the communication of diagnosis and prognosis; exploring decision–making responsibilities.Eliciting preferences and values: treatment decisions Advance Care Planning and preferred place of care.Spiritual and psychosocial needs: providing emotional and psychological support for patients carers and professionals.ConclusionsWe identified a wide range of communication and decision-making concerns as well as psychosocial support adding further insight to the survey results. Both quantitative and qualitative approaches are recommended if we are to meet all stakeholders’ needs in palliative and end-of-life care.References. Higginson IJ. Research challenges in palliative and end of life care. BMJ Supportive & Palliative Care2016;6:2–4.. Nelson A. Between the lines/beyond the questions; Shared experiences of palliative and end of life care. Summary ReportJuly 2016. Available from https://www.mariecurie.org.uk/globalassets/media/documents/research/publications/beyond-the-questions-esrc-report.pdf. Palliative and end of life care Priority Setting Partnership (PeolcPSP). (2015). Final Report15 January 2015. Available from https://www.mariecurie.org.uk/globalassets/media/documents/research/PeolcPSP_Final_Report.pdf (Accessed: 30 May 2018)

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