Multidrug-resistant bacterial microorganisms (MDRO) in end-of-life care: development of recommendations for hospitalized patients using a mixed-methods approach
Palliative care professionals are frequently confronted with patients colonized or infected with MDRO. One major challenge is how to balance necessary isolation measures and social inclusion as one of the main principles of palliative and end-of-life care. To date, MDRO-specific policies and protocols vary widely between institutions. Aim: provide empirical recommendations on how to deal with hospitalized MDRO patients in end-of-life care.
Recommendations were developed based on (i) initial results of face-to-face interviews and focus groups, (ii) impartial experts’ comments and consensus on the draft via online survey and (iii) a face-to-face meeting with consortium members to finalize recommendations. Findings of 158 interviews and six focus groups (39 participants) with patients, family caregivers, staff members and institutional stakeholders contributed to the recommendations. The assessments of 17 experts were considered.
In total, 21 recommendations were approved. The recommended strategy in dealing with MDRO at the end of life allows case-based application of protection and isolation measures. MDRO diagnostics and therapy involve screening at admission. The recommendations suggest consideration of required accommodation facilities, provided material as well as staff and time resources. The recommendations further highlight the importance of providing for strategies enabling the patient’s social inclusion and provision of verbal and written information about MDRO for patients and family caregivers, transparent medical documentation, and staff member training.
The recommendations summarize the perspectives of individuals and groups affected by MDRO at the end of life and provide practical guidance for clinical routine. Further dissemination and implementation requirements are discussed and should contain the evaluation of the knowledge, views, worries, and anxieties of the target groups.
KeywordsPalliative care Terminal care Drug resistance Multiple Practice guideline Methicillin-resistant Staphylococcus aureus Empirical research
TA, MH, FAH, TA, JMT and AS designed the interview guides and conducted the interviews. TA, FAH, TA, JMT and AS conducted the focus groups. MH, FAH, TA, JMT, AS and SS analyzed the data. SS, CO, FRL, OS, CB and CS designed the research project, obtained funding and provided guidance regarding the general direction of the project. They were contributors to research conception and design. MH, FAH and SS drafted the recommendations. CB, CO, OS, CS, SS TA, FAH, AS and JMT took part in the consortium member consensus meeting. MH was the primary author. FAH, SS and CO were key contributors in writing the manuscript. TA, JMT, AS, SS, FRL, OS, CB and CS revised the draft manuscript. All authors read and approved the final manuscript for submission.
The present work was performed in partial fulfillment of the requirements for obtaining the degree “Dr. rer. biol. hum.” for the primary author MH.
This study is part of the project “M-EndoL—MRSA in end-of-life care” which was conducted with generous financial support from the German Federal Ministry of Education and Research (BMBF) (grant nr 01GY1314) and administratively monitored by the DLR Project Management Agency. The funding source was not involved in study design; in the collection, analysis and interpretation of data; in the writing of the report and in the decision to submit the paper for publication. Layout and print of the recommendations’ publication were funded by the German Association of Palliative Care (Deutsche Gesellschaft für Palliativmedizin e.V.) without any influence on the content of the recommendations.
Compliance with ethical standards
Conflicts of interest
The authors declare that they have no conflict of interest.
The consortium study was approved by the Ethics Committee of the Faculty of Medicine, FAU Erlangen: 302_13 B, 15.01.2014 and the Institutional Review Board Regensburg and by the appointed data protection officers. Participating patients, family caregivers and staff members provided written informed consent.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
- 1.European Centre for Disease Prevention and Control (ECDC) (2015) Antimicrobial resistance surveillance in Europe 2014. Annual Report of the European Antimicrobial Resistance Surveillance Network (EARS-Net). In: European Centre for Disease Prevention and Control (ed) Antimicrobial resistance surveillance in Europe 2014. Annual Report of the European Antimicrobial Resistance Surveillance Network (EARS-Net). Stockholm, http://www.ecdc.europa.eu/en/Pages/home.aspx Accessed 07 Nov 2017
- 2.World Health Organisation (2017) Antimicrobial resistance. Fact sheet. http://www.who.int/mediacentre/factsheets/fs194/en/. Accessed 07 Nov 2017
- 3.Anonymous (2014) Recommendations for prevention and control of methicillin-resistant Staphylococcus aureus (MRSA) in medical and nursing facilities. Bundesgesundheitsbl. Gesundheitsforsch. Gesundheitsschutz 57:696–732Google Scholar
- 8.Schmalz O, Grebe SO, Alefelder C, Rüden H, Raghavachar A (2010) Umgang mit Methicillinresistentem Staphylokokkus aureus (MRSA) in der Palliativmedizin. Z. Palliativmed. https://doi.org/10.1055/s-0028-1088443
- 10.Bukki J, Klein J, But L, Montag T, Wenchel HM, Voltz R, Ostgathe C (2013) Methicillin-resistant Staphylococcus aureus (MRSA) management in palliative care units and hospices in Germany: a nationwide survey on patient isolation policies and quality of life. Palliat Med 27:84–90CrossRefPubMedGoogle Scholar
- 12.Adelhardt T, Heckel M, Stiel S, Ostgathe C, Schöffski O (2016) MRE-Kolonisation oder Infektion in der Versorgung von Menschen am Lebensende (End-of-Life-Care): Handlungsanweisungen und Informationsmaterialien in zwei deutschen Krankenhäusern - Eine Dokumentenanalyse. Z Palliativmed 17:30-37Google Scholar
- 18.Heckel M, Sturm A, Herbst FA, Ostgathe C, Stiel S (2017) Effects of methicillin-resistant Staphylococcus aureus/multiresistant gram-negative bacteria colonization or infection and isolation measures in end of life on family caregivers: results of a qualitative study. J Palliat Med 20:273–281CrossRefPubMedGoogle Scholar
- 19.Raupach-Rosin H, Klett-Tammen CJ, Schmalz O, Karch A, Castell S, Mikolajczyk R (2016) “I cannot kiss my wife”—an analysis of daily experiences of MRSA-carriers. Gesundhwes 78:822–827Google Scholar
- 22.Brouwers MC, Kerkvliet K, Spithoff K (2016) The AGREE reporting checklist: a tool to improve reporting of clinical practice guidelines. BMJ i1152:352Google Scholar
- 23.Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWFM (2015) S 3-Leitlinie Palliativmedizin für Patienten mit einer nicht heilbaren Krebserkrankung, Langversion. AWMF-Registernummer: 128/001OL In: Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWFM (eds) Leitlinienprogramm Onkologie. http://leitlinienprogrammonkologie.de/Palliativmedizin.80.0.html Accessed 26 Jan 2017
- 24.Müller W, Lorenz W, Kopp I, Selbmann HK (2004) Erarbeitung von Leitlinien für Diagnostik und Therapie. Methodische Empfehlungen. Arbeitsgem Wiss Med Fachges. http://www.awmf.org/fileadmin/user_upload/Leitlinien/Werkzeuge/Publikationen/methoden.pdf. Accessed 2 Sept 2017
- 25.VERBI Software. Consult. Sozialforschung GmbH. MAXQDA. Software for qualitative data analysis. Köln, GermanyGoogle Scholar
- 27.Strauss AL, Corbin JM (1997) Grounded theory in practice. Sage Publications, Thousand OaksGoogle Scholar
- 29.Questback GmbH (2015) EFS survey, version 10.5. Software for online surveys. Köln, GermanyGoogle Scholar
- 30.Anonymous (2012) Hygiene measures for infection or colonization with multidrug-resistant gram-negative bacilli. Commission recommendation for hospital hygiene and infection prevention (KRINKO) at the Robert Koch Institute (RKI). Bundesgesundheitsbl. Gesundheitsforsch. Gesundheitsschutz 55:1311–1354CrossRefGoogle Scholar