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Table 3 Scenarios of how physicians handle situations in which patients or the patients’ family express their opinion or wish regarding the treatment of an infection

From: Factors influencing antibiotic prescribing in long-term care facilities: a qualitative in-depth study

Scenario Description of situation Relevant quotations
Physician COMPLIES with patients’/family’s WISH NOT TO TREAT Physicians indicate to not prescribe antibiotics when the patient or his/her family does not want life-prolonging antibiotic treatment (often recorded in advance care plans). Junior doctor, female, 30: “…if the family really decides not to do it [treat with antibiotics], then they accept the risk that he [the patient] will die as a result of it. And who am I to say well I am going to give antibiotics anyway. At that point that is not my role. Then I just have to accept what they want.”
Physician COMPLIES with patients’/family’s WISH TO TREAT Antibiotic treatment is considered necessary by physician.  
Antibiotic treatment is considered (partly) medically futile by physician, but:  
• family wants to have time to deliberate with a family member that cannot be reached, in case of a poor prognosis of the patient. Elderly care physician in training, female, 25: “… then I decided in consultation with his son to start the antibiotics […] because another son was on holiday […]. And we couldn’t get a hold of him on the phone.”
• physician is willing to concede to the wish of family due to unfamiliarity with the patient and inability to predict the outcome. Junior doctor, female, 30: “… if they [the family] insist, then we should do it [prescribe antibiotics] because I don’t know the man. So it’s difficult to predict. I think it won’t make much of a difference, but still, if the family really insists, then I am quite willing to prescribe [antibiotics].”
• physician considers it unethically to ignore the religion-based wish of the patient/family, in case of a poor prognosis of the patient. General practitioner, female, 38: “…I think it is very unethical to say at a moment like that I’m sorry, but you are not getting them [antibiotics]. Even if everything in me says you’re not going to make it, this is literally the last mile, but the gentleman feels like ‘I’ve done everything, if I die now then it must be God’s will’.”
• a perception that scientific research showed that the outcome of a pneumonia is not much influenced by treatment with antibiotics [in case of respiratory tract infections at the end-of-life]. Elderly care physician, male, 51: “…now we also know from scientific research that if you talk about pneumonia that the outcome […] is not really determined by whether you use an antibiotic or not. And that makes it a little easier for us to give it even when you think ‘well, if it was my mother I wouldn’t have done this’.”
• family should be allowed time to get used to the idea that the condition of a patient deteriorates. Elderly care physician, male, 48: “… I just happened to have had some patients recently of whom I thought in retrospect I just shouldn’t have done it [prescribed antibiotics]. But sometimes you do it for the family. […] In the past I used to be more principled about this, I would say look, you shouldn’t do this, and now I think well, it’s a process for them too and I do tell them [that there is not much point], but if they can’t go along with that yet then I don’t push harder.”
• patients on rehabilitation units are used to get antibiotics from their general practitioner and will consult this general practitioner if no antibiotic is provided. Nurse assistant, female, 35: “[That is because] people are a bit more articulate of course [on the rehabilitation unit]: ‘[…] I just have a urinary tract infection’. And this is treated in the home situation. So sometimes that is the reason that the physician does treat it here, sometimes […]”
Physician DOES NOT COMPLY with patients’/family’s WISH TO TREAT Antibiotic treatment is considered medically futile by physician. Elderly care physician, female, 53: “…and some patients […] then demand treatment. […] When I am convinced that ‘this is pointless, this is medically completely pointless’. Then I don’t do it [prescribe antibiotics].”
Family of a mentally competent patient wants treatment whereas the patient does not want treatment. Elderly care physician, female, 53: “Well it depends […], if someone is competent. And this person says ‘no’ [no antibiotics] but the family says ‘yes’ [give antibiotics], then I also say I won’t do that. Because your mother is quite clear about it.”