Barriers and facilitators to shared decision-making around antimicrobial prescribing during the end-of-life period: A qualitative study of Veterans, their support caregivers and their providers

Research Square (Research Square)(2023)

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Abstract Background: Antimicrobials are frequently used for palliation during end-of-life care, but adverse effects, such as antimicrobial resistance, are a concern. Shared decision-making is beneficial in end-of-life care conversations to help align antimicrobial prescribing with patient preferences. However, there is limited data on barriers and facilitators to incorporating antimicrobial prescribing discussions into shared decision-making conversations. We explored healthcare provider, patient, and support caregiver (e.g., family member or friend) perceptions of barriers and facilitators to discussing antimicrobial prescribing during the end-of-life period. Methods: We conducted semi-structured interviews at one acute-care and one long-term care facility and performed thematic content analysis. Fifteen healthcare provider and 13 palliative care/hospice care patients/support caregivers were interviewed focusing on attitudes/beliefs about antimicrobial prescribing during end-of-life patient care. Results: Qualitative interviews revealed that providers recognize the potential benefit of leveraging shared decision-making to guide antimicrobial-prescribing decisions. Barriers included limited face-to-face time with the patient and uncertainty of end-of-life prognosis. Patients/support caregivers cited trust, comprehension, and feeling heard as important characteristics which act as facilitators in fostering effective shared decision-making around antimicrobial use. Communication in which providers ensure patients are involved in shared decision-making discussions could be increased to ensure patients and their providers develop a mutually agreeable care plan. Conclusions: Shared decision-making is a practice that can guide antimicrobial-prescribing decisions during end-of-life care and, in turn, potentially minimize antimicrobial-related adverse effects. Our findings highlight an opportunity for increased shared decision-making around antimicrobial use during end-of-life care. Interventions designed to address the identified barriers to shared decision-making have potential to improve antimicrobial prescribing practices at end-of-life.
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