Antibiotic prescription for older patients in end-of-life care: a randomized survey among physicians in Switzerland

INTRODUCTION: Pneumonia is a common infection at the end of life, yet the benefits of antibiotics for symptom relief or prolonged survival remain uncertain. This study aimed to investigate physicians' attitudes and factors influencing antibiotic prescription in aspiration pneumonia in frail older patients in palliative care settings across Switzerland. METHODS: A survey was conducted among physicians practicing in internal medicine, geriatrics and family medicine, in hospital or ambulatory settings across Switzerland's three linguistic regions. Participants were randomized to receive one of three clinical vignettes describing a geriatric patient with aspiration pneumonia, with variations in advance directives, functional dependency and dementia status. They were asked whether they would prescribe antibiotics and to explain their reasoning. The survey also collected participant demographics, including age, linguistic region, practice setting and palliative care experience. RESULTS: Among the 195 participants, 22.1% opted to prescribe antibiotics. The primary reason for prescribing antibiotics was to alleviate dyspnea. Physicians were significantly more likely to prescribe antibiotics for patients with better functional status. Notably, 76.4% believed withholding antibiotics could shorten life, while 77.9% did not think antibiotics improved comfort. Physicians practicing in French-speaking regions were more likely to prescribe antibiotics than their counterparts in German- and Italian-speaking regions (33.7% vs 13.8% and 11.1% respectively.) Age, practice setting and palliative care experience were not significantly associated with prescribing behaviour. Additionally, 77.9% of physicians stated that they would modify their decision if the patient's family disagreed with their initial choice. CONCLUSION: These findings highlight ongoing uncertainties and cultural variations in antibiotic prescribing practices at the end of life, highlighting the need for clinical decision-support tools and educational resources directed not only at physicians, but also at nursing teams, families, and caregivers. In the context of an aging population and rising antimicrobial resistance, a deeper understanding of the factors influencing antibiotic use in palliative care is essential to inform the development of targeted antimicrobial stewardship interventions aligned with patient values and palliative care goals.