Antimicrobial Use in Patients on a Comfort Care Protocol: A Retrospective Cohort Study.

BACKGROUND: Antimicrobials are commonly used in patients near the end of life, but the percentage and predictors of patients prescribed antibiotics while hospitalized on a comfort care protocol are unknown. OBJECTIVE: To determine how often patients in the acute care setting are continued on antimicrobials when they are transitioned to comfort-focused care and to describe patient characteristics correlated with antimicrobial use. DESIGN: Retrospective cohort study conducted from June 2012 to August 2014. SETTING: Two interrelated academic medical centers. PATIENTS: Inpatients >18 years old transitioned to a comfort care protocol. MEASUREMENTS: Administration of antimicrobials to patients on the comfort care protocol. ANALYSIS: We generated descriptive statistics and used a modified Poisson regression to estimate unadjusted and adjusted associations along with 95% confidence intervals (CIs) and p-values. RESULTS: There were 1881 patients included in the study; 77% of patients ultimately transitioned to a comfort care protocol received antimicrobials during their admission and 82% died in hospital. Of the 711 alive at ≥24 hours after comfort care orders, 111 (15.6%) were still on antimicrobials. After adjusting for age, a documented infection was positively associated with being on antibiotics (adjusted relative risk [ARR] = 1.46, 95% CI: 1.00-2.12, p = 0.05). Patients in the medical and surgical intensive care units (ICUs) were less likely than those on medicine to receive antimicrobials (MICU ARR = 0.32, 95% CI: 0.14-0.72, p = 0.01; SICU/Neuro ARR = 0.32, 95% CI: 0.12-0.85, p = 0.02). CONCLUSIONS: Antimicrobial use is relatively high in hospitalized patients near the end of life, even when the goal is comfort.

To Feed or Not to Feed? A Case Report and Ethical Analysis of Withholding Food and Drink in a Patient With Advanced Dementia.

It is well established that competent patients have the right to refuse artificial nutrition and hydration. There is less clarity regarding withholding nutrition in patients who lack decision-making capacity but who are still physically able to eat and drink. This case highlights the ethical dilemma of withholding food and drink in a patient with advanced dementia.