Should older persons suffering the ravages of advanced dementia be treated with antibiotics for intervening infections? The manner in which this argument is framed is in many ways predictive of how one defines personhood. Prior to antibiotics, the esteemed physician Sir William Osler described pneumonia as the “old man’s friend.” He may have been implying that infection—especially in the pre-antibiotic era—shortened terminal suffering and thereby provided a “natural” dispatch for those so afflicted. More recently however, Daniel Callahan weighed in on another ethical dilemma—feeding the dying—and alerted us to a new, but nonetheless vulnerable group in our midst. Since artificial hydration and nutrition are absolutely required for certain compromised persons to survive (e.g., during Persistent Vegetative State), the removal thereof may “become the only effective way to make certain that a large number of biologically tenacious patients actually die.”[1] Furthermore, he then identified one segment of this threatened group as the physically marginal elderly. Although the issue of artificial hydration and nutrition has not been resolved to everyone’s satisfaction, the attack on the personhood of the elderly as one member of the “biologically tenacious” group has been renewed in a different forum.
A recent peer reviewed publication examined antibiotic usage in 214 residents with advanced dementia from 21 nursing homes.[2] The authors framed their discussion in a very interesting manner. Observing that the cohort received antibiotics frequently in the latter period of their lives, the authors proceeded to caution the medical community that giving antibiotics for infections in this context would increase resistant organisms. Of course, what is implied is that a greater good for a greater number of younger, more productive individuals might predicate the withholding of antimicrobial treatment from geriatric individuals surviving with dementia. In their discussion, the researchers readily admitted that there has not been one study to date demonstrating that elderly residents of nursing homes with dementia are a threatening source of resistant bacteria after antibiotic therapy. They in essence have posited a straw man—scientifically as well ethically.
If indeed a well-designed study addressing antibiotic efficacy for physically-marginal, demented elderly is performed, its results must be framed from the perspective of personhood and dignity. Is the patient’s life meaningfully prolonged or not by antibiotic use? Do those treated suffer unreasonably from antibiotic-induced colitis? Do they die from complications contingent on the antibiotics themselves—violating primum non nocere? Induction of bacterial resistance as well as the impact thereof on society is not of primary concern. If the question of resistance is not being asked in other often younger cohorts, it cannot be asked solely with respect to the physically-marginal, demented elderly. They cannot be punished for their so-called biological tenacity.
The editorialists framed the controversy more ethically. “The solution is not to categorically deny antibiotics to the severely demented elderly, or even to impose limits on their use or their spectrum as a matter of policy. Such decisions, (would be) ethically untenable.”[3]
Although Osler may have been right in the early 20th Century, Callahan’s admonition still stands and has now moved from artificial hydration and nutrition to the aged with dementia. Its repackaging is still patently unjust.
[1] Callahan D. On Feeding the Dying. The Hastings Center Report October, 1983, page 22.
[2] D’Agata E and Mitchell SL. Patterns of Antimicrobial use among Nursing Home Residents with advanced dementia. Arch Intern Med 2008; 168:357–362.
[3] Schwaber MJ and Carmeli Y. Antibiotic Therapy in the demented elderly population. Arch Intern Med 2008; 168:349–350.
