ABSTRACT
Infection is common among advanced cancer patients. This study was undertaken to review the pattern of use of antibiotics and to identify potential factors that could affect outcomes after infection. The medical records of all patients with advanced cancer who were enrolled into the palliative care service of a district hospital during the period January, 2002 to July, 2002 were retrospectively reviewed for infections and the use of antibiotics. Among the eligible 87 patients, 17 did not have any infective episode and 70 had at least one infective episode and accounted for a total of 120 episodes. Sixty-eight episodes were associated with survival for >14 days, and 52 episodes were associated with survival of < or =14 days. The most frequent sites of infection were chest (n=63, 52.5%), urinary tract (n=35, 29.2%), and skin/wound (n=6, 5%). Antibiotics were prescribed for 97.5% (n=117) episodes. The use of second-line antibiotics was 16.2% (n=19). By multivariate logistic regression analysis, dyspnea [odds ratio (OR)=2.6, 95% confidence interval (CI)=1.1-6.3], antibiotic utilization pattern [empirical therapy (OR=4.8, 95% CI=1.7-13.2) vs. therapy according to antibiotic sensitivity], and route of administration [parenteral route (OR=3.3, 95% CI=1.3-8.2) vs. oral route] were identified as independent determinants affecting survival after infection. Dyspnea was possibly associated with poor prognosis during the treatment of infections in patients with advanced cancer, and antibiotic therapy according to sensitivity was associated with better prognosis. Further studies are encouraged to verify this. The bioethical principles on the use of antibiotics as a life-sustaining treatment should always be followed.
Subject(s)
Anti-Bacterial Agents/therapeutic use , Bacterial Infections/drug therapy , Bacterial Infections/mortality , Neoplasms/drug therapy , Neoplasms/mortality , Palliative Care/statistics & numerical data , Terminal Care/statistics & numerical data , Aged , Comorbidity , Female , Hong Kong/epidemiology , Humans , Male , Prognosis , Retrospective Studies , Risk Assessment/methods , Risk Factors , Survival Analysis , Survival Rate , Terminally Ill/statistics & numerical dataSubject(s)
Adenocarcinoma/secondary , Cytomegalovirus Infections/diagnosis , Osteomyelitis/diagnosis , Spinal Neoplasms/secondary , Spine/pathology , Adenocarcinoma/complications , Adenocarcinoma/surgery , Antiviral Agents/therapeutic use , Cytomegalovirus Infections/drug therapy , Fatal Outcome , Female , Ganciclovir/therapeutic use , Humans , Magnetic Resonance Imaging , Middle Aged , Osteomyelitis/drug therapy , Spinal Cord Compression/etiology , Spinal Neoplasms/complications , Spinal Neoplasms/surgery , Terminally Ill , Tomography, X-Ray ComputedABSTRACT
OBJECTIVES: To understand the prognostic and quality-of-life considerations surrounding life-sustaining treatment decisions for patients with advanced chronic obstructive pulmonary disease (COPD) in Hong Kong China. METHODS: A documentary review of 49 COPD patients and 19 patient case studies from the medical departments of 2 hospitals were undertaken to examine the practices of DNI decision-making (do not perform mechanical ventilation and cardiopulmonary resuscitation). Statistical, event, and thematic analyses were conducted to delineate the prognostic and quality-of-life factors that shaped the not for intubation and mechanical ventilation (DNI) decisions. RESULTS: Three major treatment-limiting decision-making patterns existed in practice: 1) Patient-initiated and shared decision-making with physician (n = 14); 2) Physician-initiated and shared decision-making with the patient/family members (n = 24); and 3) Physician-initiated DNI decision-making with patient family, but without patient participation due to mental incapacity (n = 11). Prognostic considerations include physiological parameters, performance status, concomitant diseases, therapeutic regimens, and the utilization of medical services. Three major themes were delineated regarding the way in which the patients evaluated their life quality in the context of DNI status. They are prognostic awareness, illness burdens, and existential concerns. DISCUSSION: A decision-making framework used by patients/families/physicians to limit life-sustaining treatments in patients with advanced COPD is delineated. Observations regarding how treatment limiting decision-making for patients with advanced chronic illnesses can be improved in Hong Kong are discussed.
Subject(s)
Decision Making , Family , Patient Participation , Physician's Role , Pulmonary Disease, Chronic Obstructive/therapy , Quality of Life , Respiration, Artificial , Resuscitation Orders , Aged , Attitude to Death , Cardiopulmonary Resuscitation , Female , Hong Kong , Humans , Male , Prognosis , Pulmonary Disease, Chronic Obstructive/psychologyABSTRACT
This paper evaluates the Hong Kong approach to consent regarding the forgoing of life-sustaining treatment for incompetent elderly patients. It analyzes the contextualized approach in the Hong Kong process-based, consensus-building model, in contrast to other role-based models which emphasize the establishment of a system of formal laws and a clear locus of decisional authority. Without embracing relativism, the paper argues that the Hong Kong model offers an instructive example of how strategic ambiguities can both make good sense within particular cultural context and serve important moral goals.
