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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.
ABSTRACT
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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.
INTRODUCTION
PNEUMONIA OCCURS frequently in nursing home patients.1
It is a potentially life-threatening infectious disease,1-3
especially in patients with end-stage dementia.4
From studies in US nursing homes, it seems that most pneumonias are treated
with antibiotics.5-7
Residents with pneumonia are also often admitted to the hospital.1, 8-11
However, patients with dementia are frequently excluded from studies.12 In fact, as early as 1979, withholding curative treatment
was observed in US nursing homes by Brown and Thompson.13
Their classic study on nontreatment in 9 extended care facilities in Seattle,
Wash, showed that 41% of respiratory infections were (intentionally) not treated
with antibiotics and/or patients were not hospitalized.
Moreover, during the last decade, questions have been increasingly raised
on treatment decisions for patients with advanced dementia.4, 12, 14-15
In a study on hospitalized patients, Morrison and Siu4
observed that pneumonia was not considered a terminal diagnosis in patients
with end-stage dementia, despite the high probability of death. They questioned
whether these patients should have received as many burdensome procedures
as cognitively intact persons.
With progressive dementia, patients also become incompetent to make
decisions.16-18
They become unable to balance the benefits and burdens of treatments themselves.
Physicians and families may consider curative treatment too burdensome and
benefits too small if life expectancy is short and aggressive procedures would
be required; therefore, they decide to withhold treatment.12, 19
Attempting cure may cause a burden when, for example, intravenous hydration
or antibiotics require restraints to prevent removal of the intravenous line.4, 20 In addition, the potential benefit
of treatment is decreased in patients with dementia considering their diminished
expected life span, altering the risk-benefit ratio.12
Some even raise the question if further exposure to the deteriorating course
of the dementia process represents an undue burden of pneumonia treatment.16 In considering benefits and burdens of the treatment
options, open discussions with family members are highly desirable for all
parties involved.21
Little is known about which factors influence decisions about whether
to withhold antibiotic treatment in incompetent patients. Even less is known
on variation among physicians with respect to these considerations. Until
now, studies have relied on reporting of physicians' opinions in discussions
on life-sustaining treatment22-23
or on hypothetical cases (vignettes).24-25
In the Netherlands, as in Great Britain,26
physicians are culturally and legally responsible for the ultimate decision
about withholding treatment in incompetent patients. Good practice, however,
involves consultation with families to reconstruct patients' wishes if their
present wish is unknown or to discuss what is in the patients' best interest
if no wish could be reconstructed.17, 27
In this article, we examine factors associated with the decision to
withhold antibiotic treatment in nursing home patients with pneumonia and
severe dementia and the variation among physicians regarding this decision.
Characteristics of nursing home patients with dementia, their treating physicians,
and the facilities are reviewed to look at sources of variation in withholding
antibiotic treatment. Our data provide insight into the factors that influence
decision making and should facilitate the international debate among physicians
on this controversial issue.
PATIENTS AND METHODS
Between October 1, 1996, and July 31, 1998, we identified 706 consecutive
pneumonia patients in psychogeriatric units of Dutch nursing homes in the
Pneumonia Study. Dutch nursing homes are divided into somatic (physical disability)
and psychogeriatric units. Most (96%) of the patients in the latter units
have dementia and stay within the unit the rest of their lives. Physicians
undergo a 2-year training program following their basic clinical training
to become certified as a nursing home physician. These physicians belong to
the staff of the nursing homes. Facilities employ physicians in a ratio of
1 full-time physician to 100 patients.28-31
Even after hours or on weekends, ill residents are seen at the bedside; telephone
consulting is not usual practice in the Netherlands.
The Pneumonia Study was performed in 61 facilities all over the Netherlands
affiliated with our department and covered 24% of all long-term psychogeriatric
(dementia) care beds in the country.30 Nursing
home physicians in training (similar to a residency in the United States)
at these facilities participated in the study in 2 ways: by reporting on their
own patients and by monitoring form completion on all enrolled patients in
the facility. The treating physician (whether regular staff or a trainee)
was responsible for completing all data forms. Because facilities had agreed
to participate, the physicians' effort was considered part of their employment.
The physicians were informed of the 2 main study goals: guideline development
and assessing clinical predictors for the course of pneumonia.
The patients had to meet the following criteria: (1) have a psychogeriatric
disease (almost always dementia); (2) reside in the nursing home for at least
4 weeks; and (3) be diagnosed as having pneumonia by the physician. The physicians
were explicitly instructed to include terminal patients as well. A patient
could be included only once, even if a second episode of pneumonia occurred
during the study period.
The study protocol was approved by the medical ethics committee of the
VU University Medical Center. Confidentiality of data was guaranteed by physicians
providing coded information to the researchers (as opposed to patient or physician
names). Informed consent was not deemed necessary by the ethics review committee
because physicians were simply reporting information gleaned from usual practice.
However, patients and families were informed of the study and were provided
the opportunity to refuse transfer of data to the researchers.
DATA COLLECTION
Patients were assigned to treatment solely on the basis of the decision
of the physician. Each patient was followed up for 3 months, during which
incident cure (recovery as judged by the treating physician) and death were
monitored continuously. The physicians completed questionnaires about the
patients at the time of the treatment decision that described the patient's
current condition (baseline) and their condition 2 weeks earlier (variables
recorded are displayed in Table 1
and Table 2). Rehydration therapy
was assessed 3 days after the treatment decision. Demographic data on the
physicians and the facility characteristics were obtained during site visits
by one of the authors (J.T.v.d.S.). During a limited period (from March 1,
1997, until the end of data collection), data on expected outcomes, advanced
care planning, food intake, weight loss, and vaccination for influenza were
collected.
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Table 1. Characteristics of Patients, Physicians, and Facilities Associated
With Withholding Antibiotic Treatment in Univariate Analyses
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Table 2. Characteristics of Patients, Physicians, and Facilities Not
Statistically Significantly Associated With Withholding Antibiotics in Univariate
Analyses
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We used scales specifically developed for patients with severe dementia.
Discomfort was measured at baseline (also retrospectively) using the 9-item
observational Discomfort Scale–Dementia of Alzheimer Type,32
which ranges from 0 (no observed discomfort) to 27 (high level of observed
discomfort). The physicians were instructed on the proper use of the scale
during a training session in which an instructional videotape was shown. Several
studies32-36
have demonstrated acceptable reliability and validity. A small study indicated
acceptable reliability of retrospectively assessed data (J.T.v.d.S., H.J.A.,
J. van Assendelft, MD, M. Kooistra, MD, P. Passier, MD, and M.E.O, unpublished
data, 1997). The severity of dementia before the onset of pneumonia was measured
at baseline, referring to the condition before the pneumonia, with the Bedford
Alzheimer Nursing Severity Scale (BANS-S).37
This scale consists of assessments on seven 4-point items rating cognitive
deficits, functional deficits, and occurrence of pathologic symptoms, of which
the separate items are considered relevant with respect to decision making
as well. Summed scores range from 7 (no impairment) to 28 (complete impairment).
The BANS-S is a valid measure with discriminative power even in patients with
severe dementia, including those with dementias other than Alzheimer disease.38 Subjective clinical judgment on illness severity
was rated on a numeric rating scale running from 1 (not ill) to 9 (moribund).39
STATISTICAL ANALYSIS
The patients selected for analysis in this article included those in
whom antibiotic treatment was withheld (AB-withheld) and those in whom antibiotic
treatment was promptly initiated with the explicit goal of curing the patient
(AB-curative). Patients treated with antibiotics according to the treating
physician for palliative reasons (AB-palliative) are described only. The  2 statistic for contingency tables was used to test for differences
between AB-withheld and AB-curative patients in proportions of symptom relief.
Independent sample nonparametric tests were used to compare time until death
or recovery.
The relation of patient, physician, and facility variables with the
treatment decision was first examined with univariate logistic regression
analysis. Next, using forward stepwise logistic regression analysis, a multivariable
model for withholding antibiotic treatment was constructed. Odds ratios (ORs)
and 95% confidence intervals (CIs) were computed. All facility, physician,
and patient variables that were univariately related were candidates for entry,
except for the global measure on clinical judgment of illness severity because
it was not considered specific enough to provide the desired information.
Pneumonia symptoms were grouped to assess relevance compared with other conditions.
The variables collected during a limited period were tested in the final model
only to preserve power. Accounting for the hierarchical structure of the data,
in which variables at the facility, physician, and patient level were present,
we used logistic multilevel analysis.40-41
This allows assessment of the level of variation, that is, to test whether
patient variation, physician variation, or facility variation best explains
the results. The multilevel modeling was performed with respect to variation
on the physician level. Therefore, where the random contribution to a variable
could not be neglected, there was a lack of uniformity among physicians with
respect to that variable. This implies that physicians weighed such a variable
differently in their decisions. Model performance (calibration and discrimination)42 was tested using the Hosmer-Lemeshow goodness-of-fit
statistic (C test)43 and the area under the
receiver operating characteristic curve (c statistic), respectively.44 Finally, to examine which items of the summary measures
in the model were most important, the summary measures were replaced by their
separate items. The multilevel analysis was performed with the computer program
MlwiN45; all other analyses were performed
using SPSS statistical software for Windows, version 7.5, except for model
performance, which was performed using version 9.0 (SPSS Inc, Chicago, Ill).
RESULTS
PATIENTS AND TREATMENTS
Treatment with antibiotics was withheld in 23% (AB-withheld) of the
706 patients in the Pneumonia Study. A few patients (8%) were treated with
antibiotics according to their physicians for palliative reasons (AB-palliative),
whereas all others (69%) were treated with antibiotics for curative reasons
(AB-curative).
Table 3 describes the characteristics
of the treatments used in the patients who were treated promptly. Antibiotics
were overwhelmingly given orally. In AB-withheld patients, symptom relief
in general and opiates specifically were instituted more often than in AB-curative
patients (P<.001). Only 0.6% (n = 4) of all patients
were admitted to a hospital at any time during the disease course. In these
patients, antibiotic treatment had been started in the nursing home initially.
Further analyses are restricted to the 165 AB-withheld patients and 470 AB-curative
patients treated promptly. Most patients had severe dementia (Table 4), with an average BANS-S score of 17.5. (For comparison,
in a study of Alzheimer patients, an average BANS-S score of 17.1 has been
associated with an average Mini-Mental State Examination46
score of 5.0.38)
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Table 3. Description of the Treatments Started*
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Table 4. Description of the 635 Patients Treated Without Antibiotics
or Treated With Antibiotics for Curative Reasons*
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PHYSICIANS' EXPECTATIONS
At the time of the treatment decision, the physicians expected 96% of
AB-withheld patients (55/57) to die within "a short or a somewhat longer time"
when withholding antibiotics (the sample size is smaller because we asked
this question for only a limited portion of the study). However, in 37% (n
= 21) of these cases, physicians believed that the patients would have been
cured (28% [n = 16] partly and 9% [n = 5] fully) if they had been treated
with antibiotics. The physicians expected that 98% (136/139) of the AB-curative
patients would be at least partly cured within 1 month.
FACTORS THAT INFLUENCE DECISION MAKING
Most of the more than 50 patient factors tested proved to be univariately
significantly related to withholding antibiotic treatment (Table 1 and Table 2).
The strongest association in univariate analysis was with the clinical judgment
of illness severity at the time of the treatment decision (OR, 2.7 per point
increase on a 9-point scale; 95% CI, 1.8-3.9). The illness severity of AB-withheld
patients could be characterized as severe (mean value, 7.1), and AB-curative
patients were moderately to severely ill (mean value, 5.4). Furthermore, strong
associations were found with dehydration (OR, 5.6; 95% CI, 3.9-8.3), the illness
severity 2 weeks before the treatment decision (OR, 1.9 per point increase
on the 9-point scale; 95% CI, 1.6-2.1), and eating dependency at the time
of the treatment decision (OR, 5.4; 95% CI, 3.3-9.0).
Because unexpectedly in the youngest quartile of patients (<80 years)
antibiotic treatment was more often withheld, age was tested for its relation
with a variety of possible relevant variables. The younger pneumonia patients
actually had higher scores of discomfort at the time of the treatment decision,
had more severe dementia, and were more severely ill at the time of and before
the treatment decision. Nevertheless, for these patients the illness severity
was less predictive of withholding antibiotic treatment (OR, 1.9; 95% CI,
1.4-2.4) than for older patients (OR, 3.3; 95% CI, 2.5-4.3). Of the physician
and facility characteristics, the only significant characteristic was the
number of psychogeriatric beds in the facility: a small number was predictive
of withholding antibiotic treatment more frequently (OR, 1.2 per 50 beds less;
95% CI, 1.1-1.4).
FACTORS THAT INFLUENCE DECISION MAKING INDEPENDENTLY
Illness severity by clinical judgment seemed to be the strongest independent
predictor of withholding antibiotic treatment. Table 5 gives a more specified model, which did not include illness
severity, and shows that the most important independent predictors of withholding
antibiotic treatment were all patient factors. Severe dementia was the strongest
predictor in this model. Other independently significant predictors were number
of symptoms of pneumonia, insufficient drinking, dehydration, treatment in
the summer, aspiration, and previous pneumonia.
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Table 5. Predictive Multilevel Model of Withholding Antibiotic Treatment
in Contrast to Curative Antibiotic Treatment*
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The most significant item of the BANS-S for severity of dementia with
respect to withholding antibiotic treatment proved to be eating dependency
2 weeks before the treatment decision. Likewise, of pneumonia symptoms, decreased
alertness was more important than Cheyne-Stokes respiration, tachypnea, coughing,
respiratory distress, fever, malaise, and abnormal chest auscultation.
Advanced care planning (results used in decision making in 59% of cases),
if included in the final model of Table
5 (data not shown), was also an important independent predictor
(OR, 3.3; 95% CI, 1.4-7.4; n = 243). It hardly affected the ORs of the other
variables in the model. In addition, there were no significant differences
in the characteristics of the model between patients for whom advanced care
planning had taken place and for whom this had not taken place (total group,
AB-curative, or AB-withheld).
VARIATION IN CONSIDERING PATIENT CHARACTERISTICS
Facilities varied negligibly in withholding antibiotic treatment (variation
on nursing home level in multilevel analyses). However, variation with respect
to withholding antibiotic treatment at the physician level was about 5 times
larger than at the patient level. This was owing to variation in importance
for withholding antibiotic treatment attributed to certain patient characteristics.
Namely, the best fitting model allowed random variation for 3 of the 8 factors
in the model of Table 5 (age,
aspiration, and having previously had pneumonia). This indicated that for
these factors, the OR varied among physicians. The individual physicians seemed
to vary in the degree to which these predictors were considered when deciding
to withhold treatment. Thus, the physicians varied more in their treatment
of patients younger than 80 years as opposed to older patients, in patients
who previously had pneumonia as opposed to not having prior pneumonia, and
in patients who were thought to have aspirated compared with patients for
whom this was not thought to be the cause of pneumonia.
The values of the other 5 predictors in the multilevel model of Table 5 seemed almost equally important
among individual physicians when deciding to withhold antibiotic treatment.
Modeling only these 5 predictors (dementia severity, number of pneumonia symptoms,
insufficient drinking, dehydration, and treatment in the summer) showed that
model discrimination was as good as discrimination of the complete model,
including the variables that showed random variation (area under receiver
operating characteristic curve, 0.85 compared with 0.86 for the complete model),
as could be expected.
DISEASE COURSE
Most of the AB-withheld patients (90%) died within 1 month, as did 48%
of the AB-palliative patients. Of the AB-curative patients, 27% died within
1 month. Moreover, most of the AB-withheld patients who died during the 3-month
follow-up period died within a few days (median, 2 days), which was considerably
earlier than the AB-curative patients who died despite antibiotic treatment
(median, 11.5 days; all P<.001 in this section).
Median time until death of AB-palliative patients was 5.5 days. Twelve AB-withheld
patients survived. The time for their recovery (median, 9.5 days) was not
significantly different from the recovery time of the AB-curative patients
(median, 10 days). Median recovery time for AB-palliative patients was 9 days.
COMMENT
Most patients with dementia in Dutch nursing homes who develop pneumonia
are treated with antibiotics, typically given orally. Nevertheless, in 23%
of patients, antibiotic treatment is withheld. Physicians think antibiotics
could have saved the lives of 37% of these patients. Almost two thirds were
expected to have died even if treated with antibiotics. Characteristics of
facilities, such as religious affiliation, and physician characteristics were
not associated in multilevel analysis with the treatment chosen and thus did
not seem to substantially influence the decision making. Several patient characteristics
entered as fixed effects at the physician level in the multilevel model and
thus seem to be uniformly considered by physicians in decision making. However,
3 variables entered as random effects at the physician level, which suggests
substantial variation among physicians in how these patient characteristics
are considered in decision making.
The typical patient with dementia in whom antibiotic treatment is withheld
is severely ill. Patients have severe dementia, have severe pneumonia (many
symptoms), have low intake of food and fluids, and are often dehydrated. In
addition, withholding antibiotics occurs more often in the summer. These characteristics
alone are highly predictive of withholding treatment (apparent from excellent
model fit), and they are considered in the same way. However, variation occurs
on the importance placed on not having had pneumonia previously, aspiration,
and a relatively young age. Most physicians and families were inclined to
treat with antibiotics those patients who had survived pneumonia before and
for most of whom (96%) an active approach had been used. In contrast, others
seemed to consider recurrent pneumonia one of the reasons to withhold antibiotic
treatment. Similarly, some physicians (and families) tended to withhold treatment
in patients who aspirated or were relatively young, whereas others did not.
Management of pneumonia in advanced dementia may exhibit considerable
variation in treatment internationally. Our findings suggest that Dutch physicians
tend to uniformly withhold antibiotics in some patients but vary in the weight
they place on other factors. Variation might be expected to be even greater
in countries such as the United States where there is much less ethical or
legal clarity about when to initiate a strictly palliative hospice approach
for dementia. Our findings illuminate the international discussion on this
topic by showing which patients do not receive antibiotic treatment in a setting
where such practices are common.
Severity of dementia (or deterioration) has been associated with withholding
antibiotic treatment independently in both the current study and other observational
studies.13, 47 In our study, patients
in whom antibiotics were withheld had an average BANS-S severity of dementia
score of 20.4. A study37 of the BANS-S suggests
that more than 90% of these patients would have a score of 0 on the Mini-Mental
State Examination.
Antibiotic treatment was also often withheld in patients with dehydration
and insufficient drinking. Antibiotic treatment may have been expected to
be less effective or to cause drug-related toxic effects.48
Furthermore, the (in)dependent intake of food and fluids may have a subjective
(symbolic) meaning as well, because effects were independent. Considerations
other than medical may also have played a role in withholding antibiotic treatment
in relatively young patients in whom, though more ill, the general illness
severity was less predictive. This was most evident for the 37% of patients
who were not treated with antibiotics but whom physicians thought could have
been cured. For three quarters of these patients, the expectation was for
only partial cure. We did not specify this, but the physicians may have feared
these patients would be cured of the pneumonia at the cost of a decreased
general condition. The occurrence of a pneumonia may have been used as an
opportunity to let the patient die a natural death. The pneumonia may have
been seen as "the old man's friend."49
Information from the literature concerning the frequency of withholding
antibiotics is limited. Earlier studies13, 47, 50-51
indicated that antibiotics were withheld in a quarter to half of patients,
but these studies were not nationwide and included less severe infections
than pneumonia. One study50 concerned a population
with severe dementia that was similar to our study. Physicians in this specific
US nursing home and the Netherlands apparently consider withholding antibiotic
treatment in pneumonia patients with dementia as an option. In frail patients
and, more specifically, in patients with severe dementia, the physicians may
have been inclined to forgo the more technical solutions often associated
with full curative treatment (intravenous antibiotics and simultaneous rehydration).12 A nonaggressive strategy in our frail study population
is also obvious from rare use of hospital transfer and procedures, such as
blood tests, x-ray examinations, tube feeding, and rehydration.
On the other hand, when cure was a goal, this was not achieved in more
than a quarter of the patients treated with antibiotics. In our study, typically
oral amoxicillin was given. In most Dutch hospitals and nursing homes, amoxicillin
is the first drug choice in case of unknown pathogens,52
which is generally sufficient since antibiotic resistance is still not a major
problem in the Netherlands.53 Physicians were
willing at times to start more invasive procedures in more severely ill patients.
Parenteral antibiotics (mostly intramuscular) were used for more severely
ill patients, although not for patients with more severe dementia (analyses
not shown). This finding suggests that withholding antibiotic treatment was
not merely because of, for example, problems with oral intake. In our study,
withholding antibiotic treatment was mostly, but not always, accompanied by
starting symptom relief. In patients treated with antibiotics, treatment to
relieve symptoms was started in only a few cases. Apparently, the integrated
approach, as suggested by Morrison and Siu,54
is not yet common practice. Antibiotics were sometimes (8%) given for palliative
reasons. However, evidence of the palliative effects of antibiotics is lacking.55
A limitation of the present study is that we did not obtain direct information
from physicians, families, or medical records about the basis for decisions
that were made. Inferences about factors considered important in the decision
are based on variables that distinguish those patients who did and did not
receive antibiotics. However, lack of variation with respect to a variable
is indirect evidence that it is not weighted significantly in decision making.
Advanced care planning is common in many of the nursing homes we studied,
and good practice includes reconsulting with the family in the acute situation,
even if advanced care planning has taken place.27
On the other hand, because the physicians did not know analyses on withholding
treatment were to be performed, it is also a strength of the design because
they were not pressured to exhibit socially desirable responses. Another limitation
concerns the diagnosis of pneumonia, which was often made without laboratory
or x-ray film confirmation. Besides a poor response to antibiotic treatment
(for example, in case of viral pneumonia), mistaken pneumonia diagnosis in
patients who in fact had chronic heart failure or pulmonary embolism may have
played a role in the patient population. However, in studying physicians'
decision making, their diagnosis is what is ultimately of relevance. Finally,
a strength of the study is limited patient variation; patients being much
the same makes it achievable to study decision making.
To our knowledge, this is the first large quantitative study in which
predictors of withholding antibiotic treatment in daily practice are assessed.
Our data may facilitate discussions on whether the identified factors should
really be important in the decision-making process and on discrepancies between
expected and actual outcomes. Furthermore, they raise questions about how
physicians should weigh patient factors in decision making on withholding
antibiotic treatment. Explicitly mentioning identified factors during advanced
care planning might be indicated.
We expect that there are some international differences in importance
attached to specific factors relating to treatment decisions. The factors
we identified relate predominantly to the dementia severity and the acute
illness. We suspect that similar factors would generally reflect current physicians'
attitudes in industrialized countries. They form a starting point for the
conceptualizing of guidelines. These predictors should be examined prospectively
for clinical2-3 but also for ethical
relevance in making decisions. Furthermore, to promote openness and responsible
decision making, it is helpful to have an ethical and legal framework for
decision making on whether to withhold antibiotic treatment.17, 27
Having a practical guideline including all these aspects is useful when discussing
antibiotic treatment options with the patient's family and also in advanced
care planning. This should promote prudent end-of-life care in frail, elderly
patients.
AUTHOR INFORMATION
Accepted for publication February 6, 2002.
This study was supported by the Society Het Zonnehuis (Utrecht, the
Netherlands) and the Dutch Ministry of Health Care, Welfare and Sport (The
Hague, the Netherlands).
We thank the nursing home physicians of the 61 nursing homes involved
in this study and the members of the Advisory Committee of the Pneumonia Study:
J. Th. M. van Eijk, PhD, C. M. P. M. Hertogh, MD, PhD, G. J. Ligthart, MD,
PhD, M. T. Muller, PhD, and G. L. Schut, MD, PhD. Furthermore, we thank Ellen
M. Buunk-Kampers for her administrative support and F. Boersma, MD, PhD, J.
W. P. M. Konings, MD, PhD, and D. R. Mehr, MD, MS, for their critical review
of early versions of the manuscript.
Reprints not available from the authors.
Corresponding author: Jenny T. van der Steen, MSc, EMGO Institute,
VU University Medical Center, Amsterdam, Van der Boechorststraat 7, 1081 BT
Amsterdam, the Netherlands (e-mail: jt.van_der_steen.emgo{at}med.vu.nl).
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.
REFERENCES
| |
1. Muder RR. Pneumonia in residents of long-term care facilities: epidemiology,
etiology, management, and prevention. Am J Med. 1998;105:319-330.
FULL TEXT
|
ISI
| PUBMED
2. Fine MJ, Smith MA, Carson CA, et al. Prognosis and outcomes of patients with community-acquired pneumonia:
a meta-analysis. JAMA. 1996;275:134-141.
ABSTRACT
3. Medina-Walpole AM, Katz PR. Nursing home-acquired pneumonia. J Am Geriatr Soc. 1999;47:1005-1015.
ISI
| PUBMED
4. Morrison RS, Siu AL. Survival in end-stage dementia following acute illness. JAMA. 2000;284:47-52.
FREE FULL TEXT
5. Fried TR, Gillick MR, Lipsitz LA. Whether to transfer? factors associated with hospitalization and outcome
of elderly long-term care patients with pneumonia. J Gen Intern Med. 1995;10:246-250.
ISI
| PUBMED
6. Mehr DR, Foxman B, Colombo P. Risk factors for mortality from lower respiratory infections in nursing
home patients. J Fam Pract. 1992;34:585-591.
ISI
| PUBMED
7. Marrie TJ, Durant H, Kwan C. Nursing home-acquired pneumonia: a case-control study. J Am Geriatr Soc. 1986;34:697-702.
ISI
| PUBMED
8. Jackson MM, Fierer J, Barrett-Connor E, et al. Intensive surveillance for infections in a three-year study of nursing
home patients. Am J Epidemiol. 1992;135:685-696.
FREE FULL TEXT
9. Beck-Sague C, Banerjee S, Jarvis WR. Infectious diseases and mortality among US nursing home residents. Am J Public Health. 1993;83:1739-1742.
FREE FULL TEXT
10. Mylotte JM, Naughton B, Saludades C, Maszarovics Z. Validation and application of the pneumonia prognosis index to nursing
home residents with pneumonia. J Am Geriatr Soc. 1998;46:1538-1544.
ISI
| PUBMED
11. Naughton BJ, Mylotte JM. Treatment guideline for nursing home-acquired pneumonia based on community
practice. J Am Geriatr Soc. 2000;48:82-88.
ISI
| PUBMED
12. Brauner DJ, Cameron Muir J, Sachs GA. Treating nondementia illnesses in patients with dementia. JAMA. 2000;283:3230-3235.
FREE FULL TEXT
13. Brown NK, Thompson DJ. Nontreatment of fever in extended-care facilities. N Engl J Med. 1979;300:1246-1250.
ABSTRACT
14. Hurley AC, Volicer BJ, Volicer L. Effect of fever-management strategy on the progression of dementia
of the Alzheimer type. Alzheimer Dis Assoc Disord. 1996;10:5-10.
FULL TEXT
|
ISI
| PUBMED
15. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA. 1999;282:1365-1370.
FREE FULL TEXT
16. Hertogh CMPM, Ribbe MW. Ethical aspects of medical decision-making in demented patients: a
report from the Netherlands. Alzheimer Dis Assoc Disord. 1996;10:11-19.
ISI
| PUBMED
17. van der Steen JT, Muller MT, Ooms ME, van der Wal G, Ribbe MW. Decisions to treat or not to treat pneumonia in demented psychogeriatric
nursing home patients: development of a guideline. J Med Ethics. 2000;26:114-120.
FREE FULL TEXT
18. Karlawish JHT, Quill T, Meier DE for the ACP-ASIM End-of-Life Care Consensus Panel. A consensus-based approach to providing palliative care to patients
who lack decision-making capacity. Ann Intern Med. 1999;130:835-840.
FREE FULL TEXT
19. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 4th ed. Oxford, England: Oxford University Press; 1994.
20. Volicer L, Rheaume YL, Brown J, et al. Ethical issues in the treatment of advanced Alzheimer dementia: hospice
approach. In: Volicer L, Fabiszewski KJ, Rheaume YL, Lasch KE. Clinical Management of Alzheimer's Disease. Rockville, Md: Aspen Publishers
Inc; 1988:167-182.
21. Hanson LC, Danis M, Garrett J. What is wrong with end-of-life care? opinions of bereaved family members. J Am Geriatr Soc. 1997;45:1339-1344.
ISI
| PUBMED
22. Levin JR, Wenger NS, Ouslander JG, et al. Life-sustaining treatment decisions for nursing home residents: who
discusses, who decides and what is decided? J Am Geriatr Soc. 1999;47:82-87.
ISI
| PUBMED
23. Goold SD, Arnold RM, Siminoff LA. Discussions about limiting treatment in a geriatric clinic. J Am Geriatr Soc. 1993;41:277-281.
ISI
| PUBMED
24. Alemayehu E, Molloy DW, Guyatt GH, et al. Variability in physicians' decisions on caring for chronically ill
elderly patients: an international study. CMAJ. 1991;144:1133-1138.
ABSTRACT
25. Molloy DW, Guyatt GH, Alemayehu E, et al. Factors affecting physicians' decisions on caring for an incompetent
elderly patient: an international study. CMAJ. 1991;145:947-952.
ABSTRACT
26. British Medical Association. Withholding or Withdrawing Life-Prolonging Medical
Treatment: Guidance for Decision-making. London, England: BMJ Books; 1999.
27. van der Steen JT, Graas T, Ooms ME, van der Wal G, Ribbe MW. When should physicians forgo curative treatment of pneumonia in patients
with dementia? using a guideline for decision-making. West J Med. 2000;173:274-277.
FULL TEXT
|
ISI
| PUBMED
28. Hoek JF, Penninx BW, Ligthart GJ, Ribbe MW. Health care for older persons, a country profile: the Netherlands. J Am Geriatr Soc. 2000;48:214-217.
ISI
| PUBMED
29. Frijters DH, Mor V, DuPaquier J-N, Berg K, Carpenter GI, Ribbe MW. Transitions across various continuing care settings. Age Ageing. 1997;26(suppl 2):73-76.
30. Institute for Health Care Information (SIG). SIG Nursing Home Information System Annual Report
Nursing Homes 1996 [in Dutch]. Utrecht, the Netherlands: SIG; 1997.
31. Ribbe MW. Care for the elderly: the role of the nursing home in the Dutch health
care system. Int Psychogeriatr. 1993;5:213-222.
FULL TEXT
| PUBMED
32. Hurley AC, Volicer BJ, Hanrahan PA, Houde S, Volicer L. Assessment of discomfort in advanced Alzheimer patients. Res Nurs Health. 1992;15:369-377.
ISI
| PUBMED
33. Hurley AC, Volicer B, Mahoney MA, Volicer L. Palliative fever management in Alzheimer patients: quality plus fiscal
responsibility. ANS Adv Nurs Sci. 1993;16:21-32.
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