Factors affecting antibiotic decision making in hospice care
Background: Despite limited evidence that antibiotics improve symptoms or quality of life in end-of-life care, antibiotic use is prevalent in hospice care. Concerns with antibiotic use in hospice include potential medication side effects, increased risk of subsequent opportunistic infections, prolonging the dying process, and potential financial burden for patient/family or the hospice programs. In addition, there is an increasing effort to reduce unnecessary or inappropriate antibiotic use to prevent development of antimicrobial–resistant organisms. To improve effective and appropriate antibiotic use in the hospice settings, it is important to understand how antibiotic decisions are made and what factors affect the decisions in current hospice practice.
Methods: In this qualitative study, nine nurses and one medical director from two hospice programs in Portland, Oregon, participated in individual interviews. Participants were asked to describe patients who were prescribed antibiotics in their hospice program and factors that they considered regarding antibiotic use in hospice settings. The factors identified in earlier interviews were member checked in later interviews. Three investigators independently read transcribed interviews and coded potential factors affecting antibiotic decisions using directed qualitative content analysis approach. The codes from three investigators were examined by the entire research team, and reiterative process of analyzing and merging codes to develop a list of factors was repeated until consensus was achieved.
Results: Participants identified patient preference as the most important factor influencing their antibiotic decisions. In some situations, the family preferences, which might be different from patients’, became the most important factor in decision making. Although the participants considered potential benefits and harms of antibiotics (e.g., improving symptoms, side effects) during decision making, these factors often yielded to patient and family preferences. Other factors that emerged included different values and approaches of non-hospice healthcare providers who prescribed antibiotics for the patient.
Implications: Participants prioritized patient and/or family preferences over concerns of benefits or harms caused by antibiotics. This is likely based on the hospice philosophy to respect patient and family preference, but also uncertainty regarding benefits and harms of antibiotics for hospice patients and need to maintain a therapeutic alliance among patient, family and care providers. Stronger evidence to support best practices for antibiotic use in hospice patients and better understanding of effective shared decision making processes are needed for nurses to improve quality of care in hospice programs.