Study suggests antibiotics overused for dying dementia patients
Elderly patients with advanced dementia are seven times more likely to receive antibiotics in their last two weeks of life than in the two months before they die, despite little evidence that the drugs prolong life or relieve suffering, a Harvard study reports. Overusing the drugs can contribute to the development of microbes resistant to antibiotics, a public-health hazard common in nursing homes.
Researchers from Harvard Medical School studied more than 214 patients with an average age of 85 in 21 Boston-area nursing homes. Ninety-nine patients died during the 18-month study, which the authors say is the first to look at antibiotic prescriptions for people in the end stages of dementia. All the patients were in such severe cognitive decline that they could talk little if at all, could not walk, were incontinent, and needed help with eating.
Two-thirds of the patients received at least one course of antibiotics during the study period, with an average of four courses being given, authors Dr. Ericka D’Agata and Dr. Susan L. Mitchell write in the Archives of Internal Medicine. Most patients got the drugs intravenously, which can be uncomfortable, and some experienced troubling side effects such as diarrhea.
In the last two weeks before they died, 42 percent of patients were on antibiotics, “an extraordinary use of antimicrobials, which increased dramatically at the end of life,” Mitchell, also of the Hebrew Senior Life Institute for Aging Research, said in an interview.
“Huge amounts of antimicrobials in people who are very, very near the end of life raise questions both about the individual benefit and burden and about what is important on a broader level about preventing antimicrobial resistance,” she said.
Fevers and infections are common in people at this stage of dementia, creating an opportunity for families to be counseled ahead of time about their goals for care of their loved one at the end of this terminal disease, Mitchell said. If comfort is the key, symptoms of pneumonia, the most common infection, can be eased by oxygen or Tylenol, she said. If postponing death is the hope, there is little in the medical literature to say that antibiotics help extend life.
In contrast, the growth of antibiotic resistance has been widely documented, especially in long-term care settings. Because antibiotic exposure is the greatest risk factor for antibiotic resistance, Mitchell said, treating dying dementia patients with antibiotics may promote resistance.
In an accompanying editorial, Dr. Mitchell J. Schwaber and Dr. Yehuda Carmeli of Tel Aviv Medical Center argue that using antibiotics in these patients requires the same degree of ethical deliberation as avoiding them.
“If there is no benefit to the individual patient, the good of the public health demands that antibiotic use be withheld,” they write. “We must … begin to consider every decision to use antibiotics in this population as we would decisions regarding other treatment modalities, including resuscitation and major surgery.”
Alice Bonner, director of clinical quality at the Massachusetts Extended Care Federation, a nursing-home association, said the study points out the need for more discussion of advance directives, the documents that patients and families use to make their wishes known at the end of life. Antibiotic use in advanced dementia is very common, she said in an interview, but less often broached in family meetings than decisions on resuscitation or intubation, both of which arise less often than antibiotic use.
“This is a huge issue that providers -- nurses, physicians, all of us who work in nursing homes --deal with a lot,” said Bonner, who has worked as a geriatric nurse practitioner in nursing homes for 20 years. “There’s a need for more education around these advanced directives and end-of-life issues so the public is more knowledgeable and understands through studies like this that we aren’t really helping patients by doing these things.”
I have to agree 100% with this study having suffered with my brother's last days suffering from dementia (alzheimers). Thank God, the attending physician recognized the desires of my brother's wife and the living will not to do anything but keep my brother comfortable. All antibiiotics and intravenous feeding were immediately ceased and "comfort" medication initiated. Anything would have prolonged the pain for my sister-in-law.
Doctors are caught in a dilemma. They can be sued for negligence if they don't treat the patient with an infection. Different family members may not be in agreement regarding how aggressive to be, and may become unhappy if their particular viewpoint isn't followed. If someone who wants all the stops pulled out for grandma becomes hostile about perceived neglect, they could even press chartes for "elder abuse." This is not as simple of an issue as some would like to believe.
Dying becomes an appropriate term only after someone is dead. People who are supposedly dying sometimes don't die. Dementia does not improve. Without explaining how an individual who receives a dose of antibiotics is causing a public health menace, this article is absurd
There is always the comment that sometimes people recover from the pneumonia. Well sometimes the dead come back to life (Lazurus or misdiagnosed or etc) -- does that mean we should give antibiotics to the dead?
Also patients may recover from an infection but never from the advanced dementia.
And are you forcing them through more pain for your pleasure (religious or otherwise) and profit (dates on wills, etc) ?
The default should be no abnormal medication and NDR -- unless the patient specifies otherwise. Or at least we can start with unless the immedaite family or court specifies otherwise.
If God wants to work a true miracle for the known dying...I don't think he requires extraordinary doctor assistance. Doctor's are for when their is a measurable chance of profitable recovery.
When my mother-in-law lay dying of sepsis -- or so we thought--at Emerson Hospital in Concord, Mass., we were told that we had the option of witholding antibiotics. This came as a surprise to us, as it felt like witholding a life-saving therapy. But caregivers explained that antibiotics could indeed be withheld in her case, just as food or a breathing tube could.
As it turned out, my mother-in-law finished her course of antibiotics and recovered, against everyone's expectations. Though her quality of life was poor, she lived another year and, I'm sure, was glad of it.
This is such an individual decision. Each family is different. Personally, I think it's crazy to use antibiotics on a person with advanced dementia. My 83-year-old father died of aspiration pneumonia after an eleven year course of Alzheimer's, and I wouldn't have wanted his struggle with Alzheimer's to continue. The last few years, he suffered so, as did my mother as she watched this gentle man slowly slip into aggression and violence. We had to medicate him so he wouldn't be a danger to himself or others. Then, because of the medication, he could no longer walk or interact. It was heartbreaking for all of us. Sometimes I think these infections are God's way of saying, "let nature take its course." But I know others may disagree. It's really up to each family.
To withhold antibiotics from a dying dementia patient may be appropriate in some cases - what I question is the idea of making a patient dying of pneumonia "comfortable" with oxygen and tylenol. Does this really work in practice, or is it time that we faced reality and administered the right amount of morphine in hospitals as well as in hospice?
People have to remember that antibiotics are only effective with bacterial infections; not viral. Giving antibiotics to patients with viral infections for decades has led to the current problem with antibiotic, resistant bacteria.
Also, for patients in the end stages of a disease, which is very evident, treating them with IV meds (and the IVs are painful and expensive) for just a few more days of life, isn't ethical or reasonable.
I feel for the person who wrote that their relative lived for another year, but didn't have good quality of life. You are not that person in bed, suffering. There's more to life than just breathing. Patients go through so much and the outcome is death, which for them is a blessing. Please talk to people and get in writing what they want to experience, not what you want. And remember, some day it may be your turn. Do you want to be lying there, minute after minute in pain, being stuck with needles, with no end in sight, just to keep your relatives happy?
i think this country has gone to the dogs..the medical prefession doesnt care about anyone passed 80
and doctors dont care anymore..nor do some of the people in this country
ah yes.
Why waste antibiotics on useless old people? Maybe because they are human beings ?
Essentially you are saying they are worthless life so kill them all...but since it's illegal, just don't treat their infections so they die more quickly.
But some of them don't die, they will just suffer more and then recover.
This blogger might want to review your comment before posting it.
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