Antibiotics overused in dementia patients

Study raises ethical questions about withholding treatment for the
dying
The Associated Press
updated 3:04 p.m. CT, Mon.,
Feb. 25, 2008

CHICAGO - A woman dying of Alzheimer's has a fever. Should she be
given antibiotics?

Many people would say yes. But a provocative new study suggests that
antibiotics are overused in people dying of dementia diseases and
should be considered more carefully because of the growing problem of
drug-resistant superbugs.

The study raises ethical questions about when it's acceptable to
withhold perhaps futile treatment and let people die, and whether
public health issues should ever be considered.

"Advanced dementia is a terminal illness," said study co-author Dr.
Susan Mitchell, a senior scientist with the Harvard-affiliated Hebrew
Senior Life Institute for Aging Research in Boston. "If we substituted
'end-stage cancer' for 'advanced dementia,' I don't think people would
have any problem understanding this."

Many experts, including the Alzheimer's Association, consider
Alzheimer's and other dementias to be fatal brain diseases. Patients
die of infections such as pneumonia and other complications, but the
underlying cause is damage to brain cells.

In the study, more than 200 people with advanced dementia from Boston-
area nursing homes were followed for 18 months or until their deaths.
Almost half died during that time. All the patients failed to
recognize loved ones, had stopped speaking, were unable to walk or
feed themselves and were incontinent.

"They were at what anyone would consider the very final stage,"
Mitchell said.

Researchers reviewed medical records to see what kind of care they
were given and found that 42 percent received antibiotics -- many
intravenously -- within two weeks of their deaths. The closer they were
to death, the more likely they were to receive antibiotics.

The study appears in Monday's Archives of Internal Medicine.

Antibiotic overuse contributes to the rise of superbugs, so experts
have been calling on doctors to curb the liberal prescribing of
antibiotics in many types of patients, including children with
earaches and adults with sore throats.

Nursing homes often harbor drug-resistant bacteria, prior studies have
shown, and residents can spread dangerous infections when they are
admitted to hospitals.

Doctors only see patients once a month
Dr. Daniel Brauner, a geriatrician and ethicist at the University of
Chicago Medical Center who was not involved in the study, said
cautious use of antibiotics in nursing homes would require doctors to
more closely monitor residents.

"But the standard of care (in nursing homes) is for doctors to see
residents once a month, or once every two months," Brauner said. "I'm
sure a lot of these antibiotics were prescribed over the telephone."

Doctors should discuss antibiotics with family, just as they would
discuss placing a feeding tube, Mitchell said. None of the residents
in the study who received antibiotics had living wills spelling out
their wishes on antibiotic treatment, she said.

If the family's goal is to keep their loved one comfortable, rather
than to prolong life, alternatives such as oxygen and Tylenol can
help, she said.

Giving antibiotics is sometimes appropriate for such patients, she
acknowledged.

"Maybe it's important for the family for the patient to live two weeks
longer, or if they have a bad pneumonia and they're suffering and
they're coughing," she said.

An accompanying editorial in the journal cautions that public policy
limiting antibiotics to patients with advanced dementia would be
"ethically untenable." But the editorial calls on doctors to consider
the public health ramifications when prescribing antibiotics to such
patients.

Other experts disagreed.

"Until that decision is made that death is imminent, there's always
hope," said Dr. Eric Tangalos, a geriatrician at Mayo Clinic in
Rochester, Minn., who was not involved in the study. "People do
recover from those infections."

An acceptable end
Once called "the old man's friend," pneumonia can be an acceptable end
when a patient's quality of life is extremely low and everyone agrees
the patient would want a dignified death, said another expert not
involved in the study.

"You might rescue the patient from life-threatening pneumonia and they
live a few days, weeks or even months longer," said Bruce Jennings, a
bioethicist with the Hastings Center, a research institute on medical
ethics. "But the extra time you have bought them by that rescue is not
beneficial."

(c) 2008 The Associated Press
(c) 2008 MSNBC.com