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Abstract
Background
Evaluating end-of-life (EOL) antimicrobial prescribing practices may guide stewardship efforts.
Methods
We conducted a 27-item survey of attending physicians, physician assistants, and nurse practitioners at Yale New Haven Hospital from January 2018 to February 2018 using REDCap.
Results
Of 275 providers surveyed, 109 (40%) responded. Regardless of specialty, most consider withholding antimicrobials at EOL (n = 73/109, 67%), view IV antimicrobials as escalation of care (n = 66/109, 61%), believe decision-making should involve patients and providers (n = 101/109, 93%), and recognize diarrhea as an adverse effect (n = 97/109, 89%; Table 1). However, among the subset who conduct advance care planning (N = 82), only 49% (N = 40/82) discuss antimicrobials.
Conclusion
Despite agreement in EOL prescribing practices across specialties, antimicrobials are not routinely addressed during advance care planning. These data support the integration of antimicrobial use into advance care plans linked to stewardship programs.
End-of-Life Prescribing Practices, N (%)
| Characteristic | Specialty | Years Practicing | ||||||
|---|---|---|---|---|---|---|---|---|
| Overall N = 109 | Hematology Oncology N = 49 | Infectious Diseases N = 23 | Pulmonary Critical Care N = 23 | Geriatrics Primary Care N = 10 | Palliative Care N = 4 | < 10 N = 52 | ≥ 10 N = 57 | |
| Advance Care Planning | ||||||||
| Conduct above | 82 (75) | 41 (84) | 15 (65) | 12 (52) | 10 (100) | 4 (100) | 35 (67) | 47 (83) |
| Discuss antimicrobials | 40 | 21 | 8 | 5 | 5 | 1 | 16 | 24 |
| Barriers to Addressing Antimicrobials | ||||||||
| Lack of time | 36 (33) | 15 (31) | 10 (44) | 7 (30) | 2 (20) | 2 (50) | 17 (33) | 19 (33) |
| Family members | 57 (52) | 28 (57) | 16 (70) | 10 (44) | 2 (20) | 1 (25) | 34 (65) | 23 (40) |
| Litigation fear | 25 (23) | 11 (23) | 8 (35) | 6 (26) | 0 (0) | 0 (0) | 15 (29) | 10 (18) |
| Decision Making | ||||||||
| Patient provider together | 101 (93) | 43 (88) | 22 (96) | 22 (96) | 10 (100) | 4 (100) | 47 (90) | 54 (95) |
| Withholding Antimicrobials | ||||||||
| Consider above | 73 (67) | 35 (71) | 15 (65) | 10 (46) | 9 (90) | 4 (100) | 33 (64) | 40 (71) |
| Deem unethical | 8 (7) | 5 (10) | 1 (4) | 2 (9) | 0 (0) | 0 (0) | 4 (8) | 4 (7) |
| Escalation of Care | ||||||||
| IV antimicrobials | 66 (61) | 26 (53) | 15 (65) | 16 (70) | 6 (60) | 3 (75) | 26 (50) | 40 (70) |
| Restricted antimicrobials | 66 (61) | 26 (53) | 14 (61) | 17 (74) | 5 (50) | 4 (100) | 28 (54) | 38 (67) |
| IV Antimicrobial Adverse Effects | ||||||||
| Line discomfort | 81 (74) | 34 (69) | 19 (83) | 18 (78) | 8 (80) | 2 (50) | 37 (71) | 44 (77) |
| Diarrhea | 97 (89) | 43 (88) | 20 (87) | 22 (96) | 9 (90) | 3 (75) | 46 (88) | 51 (89) |
Disclosures
M. Juthani-Mehta, Iterum Therapeutics: Scientific Advisor, Consulting fee.
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Details
1 Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut
2 Department of Pharmacy, Yale New Haven Hospital, New Haven, Connecticut
3 Department of Internal Medicine, Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut
4 Department of Internal Medicine, Section of Medical Oncology, Yale School of Medicine, New Haven, Connecticut
5 Department of Internal Medicine, Section of Geriatrics, Yale School of Medicine, New Haven, Connecticut