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Withholding Antibiotic Treatment in Pneumonia Patients With Dementia
A Quantitative Observational Study
Jenny T. van der Steen, MSc;
Marcel E. Ooms, MD, PhD;
Herman J. Adèr, PhD;
Miel W. Ribbe, MD, PhD;
Gerrit van der Wal, MD, PhD
Arch Intern Med. 2002;162:1753-1760.
Background Pneumonia is a life-threatening disease in nursing home patients with
dementia. Physicians and families face choices about whether to withhold antibiotics
when patients are expected to die soon or when treatment may be burdensome.
However, little information exists on what factors influence this complex
decision-making process.
Objective To identify factors associated with decisions on whether to withhold
curative antibiotic treatment in patients with dementia who have pneumonia.
Methods We performed an observational cohort study with 3-month monitoring for
cure and death. Patients with pneumonia (N = 706) were enrolled in nursing
home units for patients with dementia from all over the Netherlands (61 nursing
homes). Characteristics of patients, physicians, and facilities were related
to the outcome of withholding antibiotic treatment.
Results In 23% of the patients, antibiotic treatment was withheld. The other
patients received antibiotics with palliative (8%) or curative (69%) intent.
Compared with the patients who received antibiotics with curative intent,
patients in whom antibiotic treatment was withheld had more severe dementia,
had more severe pneumonia, had lower food and fluid intake, and were more
often dehydrated. In addition, withholding antibiotics occurred more often
in the summer and in patients with an initial episode of pneumonia. Characteristics
of facilities and physicians were unrelated to the decision. However, considerable
variation occurred in how patient age, aspiration, and history of pneumonia
were related to decision making by individual physicians.
Conclusions In the Netherlands, antibiotic treatment is commonly withheld in pneumonia
patients with severe dementia who are especially frail. Understanding the
circumstances in which this occurs can illuminate the international discussion
of appropriate dementia care.
From the Institute for Research in Extramural Medicine (Ms van der
Steen and Drs Ooms, Adèr, Ribbe, and van der Wal), and the Departments
of Nursing Home Medicine (Drs Ooms and Ribbe), Clinical Epidemiology and Biostatistics
(Dr Adèr), and Social Medicine (Dr van der Wal), VU University Medical
Center, Amsterdam, the Netherlands.
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