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Antibiotics Questioned in Care at Life’s End
By Nicholas Bakalarm, New York Times
March 4, 2008
A yearlong study is raising questions about the widespread use of antibiotics in nursing homes to treat infections in patients with terminal dementia — a treatment that the authors suggest is of dubious value to the patients and may be dangerous in the long run.
The study found that two-thirds of the patients received antibiotics and that 40 percent of that group received them in the last two weeks of life.
Antibiotics are often prescribed for illnesses against which they are ineffective, the authors say, but even when they are properly used, the elderly and frail can be particularly susceptible to their side effects. Intravenous administration of the drugs, common in the people in this study, can be extremely uncomfortable.
And there is the risk that widespread antibiotic use can lead to the emergence of drug-resistant germs, a significant and growing public health problem.
Previous studies have found that as many as 40 percent of patients in nursing homes harbor drug-resistant bacteria.
For the study, published Feb. 25 in The Archives of Internal Medicine, researchers tracked antibiotic use among 214 patients in 21 nursing homes near Boston. Seventy percent had advanced Alzheimer’s disease, and the rest had other kinds of severe dementia.
Almost half of the prescriptions were for respiratory diseases, and more than a third were for urinary tract infections. Of the 99 patients who died during the course of the study, 52 had received antibiotics in their last eight weeks of life. An editorial accompanying the report says this finding suggests that doctors did not regularly consider whether treatment might be futile.
“It’s important for physicians to address these issues with family members or patient surrogates to determine whether or not they want their loved one to receive antibiotics, knowing that it may cause unnecessary burdens and that we’re not sure it will improve their quality of life or prolong life,” said the lead author, Dr. Erika D’Agata, an assistant professor of medicine at Beth Israel Deaconess Hospital in Boston.
There are two reasons to administer antibiotics, the authors say: to prolong life and to control unpleasant symptoms. There have been no randomized trials, but observational studies suggest that in this population, prescribing antibiotics achieves neither goal. Infections can be painful, but it is not clear that antibiotics provide relief any greater than more conservative treatments like oxygen and pain relievers.
Dr. Paul S. Appelbaum, a professor of psychiatry at Columbia who has published widely on medical ethics and the law, questioned the conclusions. “The apparent suggestion that we should not be treating persons with dementia when they develop infections rests on a normative judgment — that does not flow from these data — that their lives are worth less than the unknown degree of risk of contributing to antibiotic resistance,” Dr. Appelbaum wrote in an e-mail message.
“Although one cannot ask the patients themselves how they feel about this judgment,” he said, “many of their family members and caregivers would disagree, and our society — fortunately, in my view — has not yet reached the point where it is willing to embrace it.”
The authors acknowledge that they had tracked only days of use, and not specific dosages, and that the study of demented patients did not include a comparison group of other long-term-care residents. And, they write, it is yet to be proved that demented patients are more likely than other groups to be reservoirs of resistant organisms.
Still, they continue, infections and fevers are common in end-stage dementia, and the widespread use of antibiotics for these patients poses significant problems given the lack of demonstrable benefits. While the researchers do not suggest that antibiotic treatment be abandoned in patients with advanced dementia, they say programs and guidelines should be established to limit their use.
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