Home Palliative Service Utilization and Care Trajectory Among Ontario Residents Dying on Chronic Dialysis

Abstract

Background:Many patients who receive chronic hemodialysis have a limited life expectancy comparable to that of patients with metastatic cancer. However, patterns of home palliative care use among patients receiving hemodialysis are unknown.Objectives:We aimed to undertake a current-state analysis to inform measurement and quality improvement in palliative service use in Ontario.Methods:We conducted a descriptive study of outcomes and home palliative care use by Ontario residents maintained on chronic dialysis using multiple provincial healthcare datasets. The period of study was the final year of life, for those died between January 2010 and December 2014.Results:We identified 9611 patients meeting inclusion criteria. At death, patients were (median [Q1, Q3] or %): 75 (66, 82) years old, on dialysis for 3.0 (1.0-6.0) years, 41% were women, 65% had diabetes, 29.6% had dementia, and 13.9% had high-impact neoplasms, and 19.9% had discontinued dialysis within 30 days of death. During the last year of life, 13.1% received ⩾1 home palliative services. Compared with patients who had no palliative services, those who received home palliative care visits had fewer emergency department and intensive care unit visits in the last 30 days of life, more deaths at home (17.1 vs 1.4%), and a lower frequency of deaths with an associated intensive care unit stay (8.1 vs 37.8%).Conclusions:Only a small proportion of patients receiving dialysis in Ontario received support through the home palliative care system. There appears to be an opportunity to improve palliative care support in parallel with dialysis care, which may improve patient, family, and health-system outcomes.

KDOQI US Commentary on the 2020 ISPD Practice Recommendations for Prescribing High-Quality Goal-Directed Peritoneal Dialysis

“…Many people treated with PD face a high burden of comorbidity, short life expectancy, low quality of life, socioeconomic deprivation, and high rates of anxiety and depression. 24 Therefore, for shared decision making to be effective, engagement, education, and empowerment of these individuals are all crucial. All these goals can be achieved with person-centered care.…”

An examination of home-based end-of-life care for cancer patients: a qualitative study

“…It can reduce the number of emergency room visits [8], admissions to intensive care units [8], hospitalizations [9], hospital deaths, and health care costs [10]. It can also increase the length of the home stays of patients [11] and the rate of home deaths [8, 12, 13]. Those patients who received home-based palliative care and their families also felt safe and hopeful [14].…”

Facility Variation and Predictors of Do Not Resuscitate Orders of Hemodialysis Patients in Canada: DOPPS

“…4 A recent study of dialysis patient’s end of life (EOL) in Ontario demonstrated one-third died in intensive care unit, another one-third died in an acute care hospital or emergency department while few received palliative care. 5 These findings suggest EOL on dialysis may be suboptimal and not consistent with patient wishes.…”