End of Life, Withdrawal, and Palliative Care Utilization among Patients Receiving Maintenance Hemodialysis Therapy

Chen, Yi Jen; Thorsteinsdottir, Björg; Vaughan, Lisa E.; Feely, Molly A.; Albright, Robert C.; Onuigbo, Macaulay; Norby, Suzanne M.; Gossett, Christy; d'Uscio, Margaret; Williams, Amy W.; Dillon, John; Hickson, La Tonya J.

doi:10.2215/cjn.00590118

Cited by 47 publications

(60 citation statements)

References 41 publications

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“…Although age would be expected to be associated with death of any etiology, including withdrawal, the strength of association of older age was greater for withdrawal relative to survival than for non‐withdrawal death relative to survival. A very recent study using patient medical records also found that older age was associated with elective withdrawal, although this study was not confined to an examination of new initiates . This suggests that the possibility of elective withdrawal in the months after dialysis initiation should be especially emphasized when counseling older patients about what the postinitiation period might hold.…”

Section: Discussionsupporting

confidence: 90%

“…While non‐whites (blacks and members of other racial groups) demonstrated a modest 6‐month survival advantage compared with whites, they were less than half as likely as whites to withdraw within 6 months. This finding was also concordant with the results of a recent study in which whites were much more likely to withdraw than non‐whites . As a percentage of all early deaths, withdrawal was nearly twice as frequent in whites as in blacks.…”

Section: Discussionmentioning

confidence: 99%

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Early withdrawal and non‐withdrawal death in the months following hemodialysis initiation: A retrospective cohort analysis

Wetmore

Roetker

Gilbertson

et al. 2019

Hemodialysis International

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Introduction: Whether and how factors associated with elective hemodialysis withdrawal differ from those associated with non‐withdrawal death soon after maintenance hemodialysis initiation have not been well studied. Methods: A retrospective cohort analysis was performed using USRDS data from 2011 to 2014. Patients were randomly categorized 2:1 into training and validation samples. Elective withdrawal deaths were identified using the Death Notification form. Multinomial logistic regression was used to fit a prediction model for three outcome categories (withdrawal, non‐withdrawal death, survival at 6 months) as a function of demographic, comorbidity, and functional status. Findings: The training sample comprised 80,284 hemodialysis patients. Mean age was 71.7 ± 11.4 years, 44.9% were female, 72.9% were white, and 22.8% were black. Within 6 months, 19.1% died, of whom 2099 (2.6%) withdrew and 13,223 (16.5%) died of a non‐withdrawal cause; 13.7% of all deaths were withdrawals. Baseline characteristics and event rates were similar among the 40,142 patients in the validation sample. The model was calibrated adequately and could discriminate moderately well between withdrawal and survival (area under ROC curve [AUC]: 0.77) and between non‐withdrawal death and survival (AUC: 0.73). However, discrimination between withdrawal and non‐withdrawal death was relatively low (AUC: 0.62). Older age and white, compared with non‐white, race were each associated with greater odds of death, and these associations were stronger for withdrawal than for non‐withdrawal death. Discussion: Advanced age and white, as opposed to black, race were most strongly associated with early elective hemodialysis withdrawal compared with non‐withdrawal death. However, it is difficult to differentiate between patients who will experience early withdrawal vs. non‐withdrawal death, as many factors are similarly associated with both outcomes.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Early withdrawal and non‐withdrawal death in the months following hemodialysis initiation: A retrospective cohort analysis

Wetmore

Roetker

Gilbertson

et al. 2019

Hemodialysis International

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“…A recently published systematic review including more than fourteen million dialysis patients of six countries identified a broad range of withdrawal between 3 per 1,000 person-years in 1966 to 49% per 1,000 person-years in 2010 [19]. More recently, in a single center study of more than 1,200 incident dialysis patients in the United States withdrawal is evaluated in up to 49% of the deaths which is twice as frequent as described previously [20]. …”

Section: Discussionmentioning

confidence: 99%

Conservative Care, Dialysis Withdrawal, and Palliative Care: Results from a Survey of a Non-Profit Dialysis Provider in Germany

Pommer¹,

Wagner²,

Thumfart³

2019

Kidney Blood Press Res

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Background: In Germany, practice patterns of conservative renal care (CRC), dialysis withdrawal (DW), and concomitant palliative care in patients who choose these options are unknown. Method: A survey was designed including 13 structured and one open questions on the management and frequency of CRC and DW, local palliative care structure, and fundamentals of the decision-making process, and addressed to the head physicians of all renal centers (n = 193) of a non-profit renal care provider (KfH – Kuratorium für Dialyse und Nierentransplantation, Neu-Isenburg, Germany). Results: Response rate was 62.2% (n = 122 centers) comprising 14,197 prevalent dialysis patients and 159,652 renal outpatients. Two-thirds of the respondents were men (85% in the age group between 45 and 64 years). Mean time of experience in renal medicine was 22.2 years in men, 20.8 years in women. 94% of all centers provided CRC with a different frequency and proportion of patients (mean 8.4% of the center population, median 5%, range 0–50%). Mean proportion of DW was 2.85% per year (median 2%, range 1–15%). Physicians and center features were not significantly associated with utilization of CRC or DW. Palliative care management varied including local palliative teams, support by general physicians, or by the renal team itself. Hospice care was only established in patients undergoing CRC. Fundamentals of the decision-making process were the desire of the patient (90% in CRC, 67% in DW). Patients undergoing CRC changed their opinion towards treatment modality “frequently” in 18% of the cases, “occasionally” in 73%. Physicians’ decisions were mostly driven by presumed fatal prognosis and poor physical or mental conditions of the individual patient. Different barriers to provide palliative care for the renal population like lack of education in palliative medicine, shortness of staff, lack of financial resources, and local palliative care structures were reported. Conclusion: Compared to international numbers, in Germany, proportion of CRC and DW reported by non-profit renal centers is in the lower range. Center practice of palliative care management varies and is driven by availability of local palliative care resources and presumably by attitudes of the renal teams. Quality of palliative care and the decision-making process need further evaluation.

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“…Unfortunately, there are no specific data on QOL measures in patients with both advanced cancer and ESRD who are started on dialysis. Studies germane to QOL have shown that, among ESRD patients receiving dialysis in Canada, 61% regretted their decision to start dialysis . A recent study of 1226 patients in the US who were started on dialysis showed that, among the patients who died during the observation period, 49% had chosen to withdraw from dialysis .…”

Section: Eastern Cooperative Oncology Group (Ecog) Performance Statusmentioning

confidence: 99%

“…Having the palliative care service involved as part of the health care team also reinforces to patients and their family members that we will continue to care for them even if they decide not to initiate dialysis. Studies have consistently shown that the introduction of palliative care after the diagnosis of cancer improves QOL …”

Section: Eastern Cooperative Oncology Group (Ecog) Performance Statusmentioning

confidence: 99%

Decision making for the initiation and termination of dialysis in patients with advanced cancer

Latcha

2019

Seminars in Dialysis

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Age is a risk factor for both cancer and end‐stage renal disease (ESRD). Newer cancer treatments are allowing patients to live longer with their cancer, the renal toxicity from the cancer itself or from the therapies that was used to treat the malignancy. Consequently, nephrologists will increasingly be asked to evaluate and counsel patients with ESRD and advanced cancer regarding the initiation of dialysis. Data on morbidity, mortality, and quality of life (QOL) outcomes in this population are sparse. Expectations regarding what dialysis can reasonably accomplish in this cohort can be unrealistically high among patients, their family members and the rest of the health care team. This article will discuss some results from the available studies on mortality and QOL outcomes in this cohort and advise the nephrologist about how to approach these challenging discussions.

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End of Life, Withdrawal, and Palliative Care Utilization among Patients Receiving Maintenance Hemodialysis Therapy

Abstract: In this single-center study, the rate of hemodialysis withdrawals were twice the frequency previously described. Acute medical complications and frailty appeared to be driving factors. However, palliative care services were used in only a minority of patients.

Cited by 47 publications

References 41 publications

Early withdrawal and non‐withdrawal death in the months following hemodialysis initiation: A retrospective cohort analysis

Early withdrawal and non‐withdrawal death in the months following hemodialysis initiation: A retrospective cohort analysis

Conservative Care, Dialysis Withdrawal, and Palliative Care: Results from a Survey of a Non-Profit Dialysis Provider in Germany

Decision making for the initiation and termination of dialysis in patients with advanced cancer

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