Use of Hospice in the United States Dialysis Population

Abstract

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.

Cognitive Impairment in the Aging Dialysis and Chronic Kidney Disease Populations: An Occult Burden

“…Of the deceased hemodialysis patients in the USRDS 2001 to 2002 cohort, (n = 115,239), approximately 22 percent chose to withdraw from dialysis. Failure to thrive was the most common reason for dialysis withdrawal, identified in 42.9 percent of patients (82). Failure to thrive is a poorly defined term that usually denotes unintentional weight loss, functional dependence, depression, and confusion (83), but these symptoms also occur in patients with moderate to severe dementia.…”

Patient-Centered Care

“…Reports of limited survival and poor outcomes after initiation of dialysis, high levels of health care intensity and low rates of hospice use at the very end of life in older dialysis patients have helped to highlight the potential burdens of dialysis treatment in this most vulnerable group (24)(25)(26)(27)(28). In addition, a growing number of reports from outside the United States comparing outcomes among patients who initiate dialysis versus those treated more conservatively suggest that dialysis may have little effect on life expectancy in frail older adults, and that any gains in life expectancy may be offset by more days spent in a health care setting (29,30).…”

“…Compared with older Medicare beneficiaries with cancer, those receiving long-term dialysis spend twice as many days in the hospital during the last month of life (9.8 versus 5.1 days) and are three times more likely to undergo an intensive procedure (29.0% versus 9%) (27). By contrast, rates of palliative care and hospice utilization among dialysis patients at the end of life are about one half of that of other chronic disease populations (28). Clinicians, patients, and families often find it difficult to say "no" to intensive interventions (including dialysis) that are intended to prolong life when these are offered.…”

Dialysis in the Frail Elderly — A Current Ethical Problem, an Impending Ethical Crisis

“…17,19 The symptom burden in the elderly HD patient is heavy and rivals that of cancer, 14 yet palliative care is underutilized, even in patients who withdraw from HD. 57 Death associated with discontinuation of HD has increased from 14 % of patients 65 59 Survival of elderly patients on HD is poor. 6 A recent push toward earlier initiation of HD has failed to improve survival.…”