Abstract
BackgroundHealthcare professionals and surrogate decision-makers often face the difficult decision of whether to initiate or withhold antibiotics from people with dementia who have developed a life-threatening infection after losing decisional capacity.MethodsWe conducted a vignette-based survey among 1050 Quebec stakeholders (senior citizens, family caregivers, nurses and physicians; response rate 49.4%) to (1) assess their attitudes toward withholding antibiotics from people with dementia lacking decisional capacity; (2) compare attitudes between dementia stages and stakeholder groups; and (3) investigate other correlates of attitudes, including support for continuous deep sedation (CDS) and medical assistance in dying (MAID). The vignettes feature a woman moving along the dementia trajectory, who has refused in writing all life-prolonging interventions and explicitly requested that a doctor end her life when she no longer recognizes her loved ones. Two stages were considered after she had lost capacity: the advanced stage, where she likely has several more years to live, and the terminal stage, where she is close to death.ResultsSupport for withholding antibiotics ranged from 75% among seniors and caregivers at the advanced stage, to 98% among physicians at the terminal stage. Using the generalized estimating equation approach, we found stakeholder group, religiosity, and support for CDS and MAID, to be associated with attitudes toward antibiotics.ConclusionsFindings underscore the importance for healthcare professionals of discussing underlying values and treatment goals with people at an early stage of dementia and their relatives, to help them anticipate future care decisions and better prepare surrogates for their role. Findings also have implications for the scope of MAID laws, in particular in Canada where the extension of MAID to persons lacking decisional capacity is currently being considered.
Highlights
Healthcare professionals and surrogate decision-makers often face the difficult decision of whether to initiate or withhold antibiotics from people with dementia who have developed a life-threatening infection after losing decisional capacity
As previously reported [57], at the terminal stage, support for extending medical assistance in dying (MAID) to the patient was relatively high in all four groups, from 71% among physicians to 91% among family caregivers, and always higher than at the advanced stage
Support for MAID was higher than for continuous deep sedation (CDS) among seniors, caregivers and nurses, whereas no difference was found among physicians
Summary
Healthcare professionals and surrogate decision-makers often face the difficult decision of whether to initiate or withhold antibiotics from people with dementia who have developed a life-threatening infection after losing decisional capacity. Unless a clear and well-informed advance directive is available, choosing the best approach to life-threatening infections can be challenging, requiring surrogate decision-makers and healthcare professionals to carefully balance complex medical and ethical considerations (e.g., whether antibiotics are medically indicated or futile in the situation; cost-utility issues; whether to accept potential burden caused by treatment; weighing the patient’s best interests against patient and family preferences; balancing benefit to the present patient given antibiotics against harm to future patients due to antimicrobial resistance) [16, 21,22,23]
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