A recent study of a small sample of nursing home residents with advanced dementia revealed that although antimicrobial treatment may prolong survival, it doesn't necessarily improve comfort. In fact, more aggressive forms of the treatment, such as IV antibiotics or hospitalization, resulted in increased levels of pain, anxiety, depression, and agitation. The study investigators reviewed Boston-area data that were prospectively collected from 2003 to 2009 from 323 nursing home residents with advanced dementia. The results raise questions for caregivers, including the nurses and family members who are responsible for determining courses of treatment. Pneumonia is common in patients with advanced dementia, and given that one in four of the decisions facing families of these patients is related to infection, the study's implications are clinically significant.

So, what are nurses to do? A comment on the study, published in the Boston Globe (http://bit.ly/d2ua3J), noted that nurses, already overworked, may find themselves recommending antibiotic treatment even if they're reluctant to do so to avoid legal consequences. And nursing homes, also wary of lawsuits, tend to do the same; this "default mode" is further exacerbated by logistical problems, such as difficulty reaching a physician for consultation in the middle of the night. Ultimately, decisions have to be made, but questions remain. Does one err on the side of caution and choose hospitalization, asks the Globe article, even when discomfort may be the outcome? And at what point-and with what resources-does a nurse inform family members and surrogate caregivers of the pros and cons of antibiotic treatment, helping them to weigh prolonged life versus comfort?

"The study underscores the need for facilities to institutionalize practices that engage clinicians and families of persons with advanced dementia in establishing [specific] goals of care," said Marie Boltz, director of practice initiatives at the Hartford Institute for Geriatric Nursing at New York University. "The study will hopefully challenge nurse leaders to develop and evaluate policy that promotes self-direction in patients." Formalizing these practices, Boltz said, is the best way to ensure that nurses can provide appropriate patient-centered care without fear of reprisal.-Bethany Lyttle