There’s a myriad of ethical issues when it comes to antimicrobial resistance (AMR) and antimicrobial treatment. The use of antimicrobial therapy in older adults is but one.

A micrograph showing MRSA bacteria

“To combat antimicrobial resistance (AMR), we need a ‘one health’ approach where all the players – whether you’re in animal health, human health, or environmental health – need to come together for stewardship purposes,” said Prof Adriano Duse (head of Department of Clinical Microbiology and Infectious Diseases at Wits).

STRATEGIES FOR REDUCING AMR

The first step is to prevent transmission of antimicrobial resistant organisms from one patient to another. “We know that vaccines are the ideal way to get rid of infections, but we’re also aware that we’re falling behind in vaccine strategies,” said Prof Duse at the recent BD Healthcare Summit. “We also know that the interim responsibility of AMR lies with community practices, hospitals, and the agricultural and veterinary sectors.

There’s no doubt that surveillance, looking at cost issues, looking at integral distribution of antimicrobials, and feeding our results into the global sphere is crucial because this is something that needs to be done as a global collaborative effort.” However, Prof Duse warned healthcare professionals about their responsibility as far as AMR stewardship is concerned.

ETHICAL ISSUES RELATING TO USE OF ANTIMICROBIAL THERAPY IN OLDER ADULTS

“It’s a fact that a significant proportion of terminally ill patients receive antibiotics. But the question is why?” Prof Duse asked healthcare professionals. “It is postulated that in many cases it is simply routine. When someone spikes a temperature, we automatically put the patient on an antibiotic. The second reason is we feel so bad about the patient dying that there’s comfort in saying ‘well at least I can make something right’, even if the patient is facing an irreversible death process.

The third is a real concern as well, some people say that with all the litigation and opinions of family members, ‘If I withhold antibiotics will I not actually increase mortality to those individuals’?” Prof Duse challenged medical professionals to consider these scenarios:

  • Your mother needs antibiotic therapy but has irreversible coma or is in a persistent vegetative state but no terminal illness? What would you do? If you’re honest, do you feel it’s crucial to give those antibiotics to address your own emotions in the situation?
  • If your mother has mental incompetence, but no terminal illness, would you agree to give her antibiotics or not?
  • Your mother is in a coma with a small, but uncertain chance of recovery. Would you give your mother the antibiotic?
  • Your mother has brain damage, mental incompetence, and is terminally ill. Would you give her antibiotics?

“It is very difficult with the big medical decisions to just involve one person, which is why typically with end of life strategy you require a multidisciplinary team of people. Ideally with an ethicist who can actually take you through all the debates and discussions, so the final decision is not informed by, but guided by ethics,” said Prof Duse.