Dialysis discontinuation and palliative care

Cohen, Lewis M.; Germain, Michael J.; Poppel, David M.; Woods, Anne; Kjellstrand, Carl M.

doi:10.1053/ajkd.2000.8286

Cited by 110 publications

(87 citation statements)

References 18 publications

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“…This difference in median survival was even greater when the first 90 d on dialysis (or post-PDI) were excluded and when only nonemergency referral patients were compared with the MCM group; however, MCM patients who elected never to start dialysis commonly survived Ն1 y, which contrasts sharply with previously reported mean survival of 8 d (range 2 to 46 d) for patients who initially opted for dialysis and subsequently elected to withdraw from treatment (19). This has profound implications in deciding between pur- Figure 3.…”

Section: Discussioncontrasting

confidence: 79%

“…Overall, RRT patients spent on average 6.9% of the days they survived (25 d per patient per year) as hospital inpatients, which is similar to three studies that described incident 90-d survivor RRT patients who were aged Ͼ80 yr (20), incident peritoneal dialysis patients who were aged Ͼ75 yr (21), and RRT patients who were aged Ն70 yr; had survived Ͼ90 d (22); and were hospitalized for 35,19, and 20 d per patient per year, respectively.…”

Section: Discussionsupporting

confidence: 76%

“…The growing literature surrounding end-of-life care in renal patients has been largely centered around advanced care planning for patients who are established on dialysis and symptom control in palliative care of patients who have withdrawn from dialysis (19,(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40). The next step in improving care for patients with kidney failure is to discuss initiation of dialysis (versus MCM) earlier.…”

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

Is Maximum Conservative Management an Equivalent Treatment Option to Dialysis for Elderly Patients with Significant Comorbid Disease?

Carson

Juszczak

Davenport

et al. 2009

Clinical Journal of the American Society of Nephrology

400

388

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Background and objectives: There is ongoing growth of elderly populations with ESRD in Western Europe and North America. In our center, we offer an alternative care pathway of 'maximum conservative management' (MCM) to patients who elect not to start dialysis, often because of a heavy burden of comorbid illness and advanced age. The objective of our study was to compare clinical outcomes for patients who had ESRD and chose either MCM or renal replacement therapy (RRT).Design, setting, participants, & measurements: This is an observational study of a single-center cohort in the United Kingdom that evaluating 202 elderly (>70 yr) patients who had ESRD and had chosen either MCM (n ‫؍‬ 29) or RRT (n ‫؍‬ 173). We report survival, hospitalization rates, and location of death for this cohort. Survival was measured from a standardized 'threshold' estimated GFR of 10.

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Section: Discussioncontrasting

confidence: 79%

Section: Discussionsupporting

confidence: 76%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Is Maximum Conservative Management an Equivalent Treatment Option to Dialysis for Elderly Patients with Significant Comorbid Disease?

Carson

Juszczak

Davenport

et al. 2009

Clinical Journal of the American Society of Nephrology

400

388

View full text Add to dashboard Cite

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“…Withdrawal status was determined from the Centers for Medicare & Medicaid Services (CMS) ESRD Death Notification Form (CMS-2746), which indicates whether the patient withdrew from dialysis and lists the following possible reasons for withdrawal: (1) Access failure, (2) transplant failure, (3) chronic failure to thrive, (4) acute medical complication, and (5) other. Data were listed as missing when the CMS-2746 form was incomplete and no reason for withdrawal was indicated.…”

Section: Data Sources and Patient Populationmentioning

confidence: 99%

“…Yet most dialysis patients die in the hospital and other institutional settings without hospice care, and up to 73% die with distressing pain, severe dyspnea, and other symptoms (2). Although dialysis patients in the United States have a high symptom burden equal to that of cancer patients (3,4), their 5-year survival rate is only approximately half that of cancer patients (5,6).…”

mentioning

confidence: 99%

Use of Hospice in the United States Dialysis Population

Murray

Arko

Chen

et al. 2006

Clinical Journal of the American Society of Nephrology

141

132

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Hospice is recognized for providing excellent end-of-life care but may be underused by dialysis patients. Hospice use and related outcomes were measured among dialysis patients, and factors that were associated with hospice use were identified. The 2-yr US Renal Data System dialysis patients who died between January 1, 2001, and December 31, 2002, and hospice claims from the Centers for Medicare & Medicaid Services were examined to measure prevalence, factors, and costs that were associated with dialysis withdrawal and hospice use. Of the 115,239 deceased patients, 21.8% withdrew from dialysis and 13.5% used hospice. Of those who withdrew, 41.9% used hospice. Failure to thrive was the most common reason for dialysis withdrawal (42.9%). On multivariable logistic regression analysis, factors that were significantly associated with hospice referral among patients who withdrew from dialysis were age, race, reason for withdrawal, ability to walk or transfer at dialysis initiation, and state of residence. Among patients who withdrew from dialysis and used hospice, median cost of per-patient care during the last week of life was $1858, compared with $4878 for nonhospice patients (P < 0.001); hospitalization costs accounted for most of that difference. Only 22.9% of dialysis hospice patients died in the hospital, compared with 69.0% of nonhospice patients (P < 0.001). A minority of dialysis patients use hospice, even among patients who withdrew from dialysis, whose death usually is certain. Increased hospice use may enable more dialysis patients to die at home, with substantial cost savings. Research regarding additional benefits of hospice care for dialysis patients is needed.

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Practical Considerations in Dialysis Withdrawal

Cohen¹,

Germain²,

Poppel³

2003

JAMA

Self Cite

104

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Mr D was a 78-year-old man with end-stage renal disease (ESRD) from diabetes and hypertensive nephrosclerosis. He had a prior history of multiple episodes of aspiration pneumonia. For the past 2 years Mr D resided in a convalescent home, where he was visited frequently by his daughter, son, and their families. Mr D was transferred from his skilled nursing facility to the university hospital with cough, fever, and hypoxia.Mr D had had diabetes for 10 years, with repeated hospitalizations for nonketotic hyperosmolar state. Comorbid disorders included vascular dementia, atrial fibrillation, chronic lymphocytic leukemia, emphysema, pleural effusion, colonic diverticulosis, and tubular adenoma. Hemodialysis was begun 30 months prior to his final admission, but he became progressively more lethargic, less verbal, and physically weaker. A formal advance directive was never completed. On several occasions Mr D's children, and both Dr A, his family practice physician, and Dr E, his nephrologist, had discussed Mr D's deteriorating condition and the treatment alternatives that were available, including cessation of dialysis. For some time the family disagreed with respect to the goals of treatment. Despite the episodic illnesses, Mr D still seemed to relish eating and clearly enjoyed visits. Nonetheless, the repeated hospitalizations and Mr D's failure to regain his baseline status after each episode weighed heavily on his children.By the time of his most recent hospitalization, he was no longer able to eat, and talk turned to a feeding tube and other invasive support. His family painfully deliberated over this course of action and finally agreed to dialysis cessation. Mr D was unable to meaningfully participate in this decision. Five days following his last session, Mr D died in the palliative care unit of the hospital.

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Dialysis discontinuation and palliative care

Cited by 110 publications

References 18 publications

Is Maximum Conservative Management an Equivalent Treatment Option to Dialysis for Elderly Patients with Significant Comorbid Disease?

Is Maximum Conservative Management an Equivalent Treatment Option to Dialysis for Elderly Patients with Significant Comorbid Disease?

Use of Hospice in the United States Dialysis Population

Practical Considerations in Dialysis Withdrawal

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