• Rupak Datta, Jeffrey Topal, Dayna McManus, Tara Sanft, Louise Marie Dembry, Laura J Morrison, Vincent Quagliarello, and Manisha Juthani-Mehta.
• Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA.
• Palliat Med. 2021 Jan 1; 35 (1): 236-241.

BackgroundAntimicrobial use during end-of-life care of older adults with advanced cancer is prevalent. Factors influencing the decision to prescribe antimicrobials during end-of-life care are not well defined.AimTo evaluate factors influencing medicine subspecialists to prescribe intravenous and oral antimicrobials during end-of-life care of older adults with advanced cancer to guide an educational intervention.Design18-item single-center cross-sectional survey.Setting/ParticipantsInpatient medicine subspecialists in 2018.ResultsOf 186 subspecialists surveyed, 67 (36%) responded. Most considered withholding antimicrobials at the time of clinical deterioration during hospitalization (n = 54/67, 81%), viewed the initiation of additional intravenous antimicrobials as escalation of care (n = 44/67, 66%), and believed decision-making should involve patients or surrogates and providers (n = 64/67, 96%). Fifty-one percent (n = 30/59) of respondents who conducted advance care planning did not discuss antimicrobials. Barriers to discussing end-of-life antimicrobials included the potential to overwhelm patients or families, challenges of withdrawing antimicrobials, and insufficient training.ConclusionsAlthough the initiation of additional intravenous antimicrobials was viewed as escalation of care, antimicrobials were not routinely discussed during advance care planning. Educational interventions that promote recognition of antimicrobial-associated adverse events, incorporate antimicrobial use into advance care plans, and offer communication simulation training around the role of antimicrobials during end-of-life care are warranted.

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