title: Withholding antibiotic treatment in pneumonia patients with dementia: a quantitative observational study.
abstract: BACKGROUND
  Pneumonia is a life-threatening disease in nursing home patients with dementia. Physicians and families face choices about whether to withhold antibiotics when patients are expected to die soon or when treatment may be burdensome. However, little information exists on what factors influence this complex decision-making process.
  
  
  OBJECTIVE
  To identify factors associated with decisions on whether to withhold curative antibiotic treatment in patients with dementia who have pneumonia.
  
  
  METHODS
  We performed an observational cohort study with 3-month monitoring for cure and death. Patients with pneumonia (N = 706) were enrolled in nursing home units for patients with dementia from all over the Netherlands (61 nursing homes). Characteristics of patients, physicians, and facilities were related to the outcome of withholding antibiotic treatment.
  
  
  RESULTS
  In 23% of the patients, antibiotic treatment was withheld. The other patients received antibiotics with palliative (8%) or curative (69%) intent. Compared with the patients who received antibiotics with curative intent, patients in whom antibiotic treatment was withheld had more severe dementia, had more severe pneumonia, had lower food and fluid intake, and were more often dehydrated. In addition, withholding antibiotics occurred more often in the summer and in patients with an initial episode of pneumonia. Characteristics of facilities and physicians were unrelated to the decision. However, considerable variation occurred in how patient age, aspiration, and history of pneumonia were related to decision making by individual physicians.
  
  
  CONCLUSIONS
  In the Netherlands, antibiotic treatment is commonly withheld in pneumonia patients with severe dementia who are especially frail. Understanding the circumstances in which this occurs can illuminate the international discussion of appropriate dementia care.
authors.affiliation: Institute for Research in Extramural Medicine, Amsterdam, the Netherlands. jt.van_der_steen.emgo@med.vu.nl
authors.forename: Jenny T
authors.initials: JT
authors.lastname: van der Steen
authors.forename: Marcel E
authors.initials: ME
authors.lastname: Ooms
authors.forename: Herman J
authors.initials: HJ
authors.lastname: Adèr
authors.forename: Miel W
authors.initials: MW
authors.lastname: Ribbe
authors.forename: Gerrit
authors.initials: G
authors.lastname: van der Wal
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D003657:Decision Making; D003704:Dementia / Q000150:complications* / Q000188:drug therapy* / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D009426:Netherlands; D010820:Physicians / Q000523:psychology; D011014:Pneumonia / Q000150:complications* / Q000188:drug therapy* / Q000401:mortality; D012720:Severity of Illness Index; D016019:Survival Analysis; D016896:Treatment Outcome; D028761:Withholding Treatment
chemical_list: D000900:Anti-Bacterial Agents
keywords: Death and Euthanasia; Empirical Approach; Mental Health Therapies; Professional Patient Relationship