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Physician Perceptions Regarding Antimicrobial Use in End-of-Life Care

Published online by Cambridge University Press:  12 February 2018

Christopher E. Gaw*
Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
Keith W. Hamilton
Division of Infectious Diseases, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
Jeffrey S. Gerber
Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
Julia E. Szymczak
Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
Address correspondence to Christopher E. Gaw, MD, MBE, Division of General Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 (



The decision to utilize antimicrobials in end-of-life situations is complex. Understanding the reasons why physicians prescribe antimicrobials in this patient population is important for informing the design of antimicrobial stewardship interventions.


A 51-item survey containing both closed and open-ended questions on end-of-life antimicrobial use was administered to physicians affiliated with the University of Pennsylvania and Children’s Hospital of Philadelphia from January through April 2017. A mixed-methods approach was used to analyze responses.


Of 637 physicians surveyed, 283 responses (44.4%) were received. Most (86.2%) physicians believed that respecting a patient’s wish to continue antimicrobials was important. Approximately half of physicians (49.8%) believed that antimicrobial use at the end of life contributes to resistance. A higher proportion of pediatricians would often or always continue antimicrobial treatment for active infections and for hospice patients whose death was imminent compared to adult physicians (P<.001). Analysis of free-text responses revealed additional reasons why physicians may continue antimicrobials at end of life, including meeting family expectations, wanting to avoid the perception of “giving up,” uncertainty about prognosis, and reducing patient pain or discomfort.


Physician decision making concerning antimicrobial use in patients at the end of life is multifactorial. Clinicians may overweigh the benefits of antimicrobial therapy in end-of-life situations and view the importance of adhering to stewardship policies differently. Pediatric and adult clinicians have different approaches to this patient population. Better understanding of the complex decision making that occurs in the end-of-life patient population can help guide antimicrobial stewardship policies and improve patient care.

Infect Control Hosp Epidemiol 2018;39:383–390

Original Articles
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved 

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