Predictors and Assessment of Hospice Use for End-Stage Renal Disease Patients in Taiwan

Abstract

Objectives: Hospice and early palliative care are generally considered as an alternative and supportive care to offer symptoms relief and optimize the quality of life among end-stage renal disease (ESRD) patients, but hospice care remains underutilized. This study aimed to examine patient and health system characteristics and develop a patient assessment scale to evaluate ESRD patients for hospice care after the implementation of non-cancer hospice care reimbursement policy in 2009 in Taiwan. Method: We conducted a retrospective cohort study using nationwide population-based datasets. Adult long-term dialysis patients between 2009 and 2012 were included. Multivariable logistic regression and the Firth penalized likelihood estimation were used to estimate the likelihood of receiving hospice care. A receiver operating characteristic curve (ROC) analysis and C-statistic were calculated to determine the optimal models for a patient assessment of hospice use. Results: Patients who were older, comorbid with anemia (odds ratio [OR] 3.53, 95% CI 1.43-8.70) or sepsis (OR 1.62, 95% CI 1.08–2.44), with longer dialysis durations, more hospitalizations (OR 4.68, 95% CI 2.56–8.55), or primary provider care with hospice (OR 5.15, 95% CI 2.80–9.45) were more likely to receive hospice care. The total score of the patient assessment scale of hospice care was 0–28 with a cut-off value of 19 based on the results of the receiver operating characteristic curve. Conclusion: Given the “Patient Right to Autonomy Act” implemented in Taiwan in 2019 to promote the concept of a “good quality of death”, this patient assessment scale may help health professionals target ESRD patients for hospice care and engage in shared decision making and the advance care planning process.

The explorations of the awareness, contemplation, self-Efficacy, and readiness of advance care planning, and its predictors in Taiwanese patients while receiving hemodialysis treatment

“…Thus, patients undergoing dialysis are more likely to encounter ethical and legal concerns related to palliative care and advance care planning (ACP), which involves advance directives (AD), health care agents, and medical decisions for end-of-life (EOL) (i.e., timing of dialysis withdraw, do not resuscitate (DNR) orders and physician orders for life-sustaining treatment). From the perspective of medical care, the assessment of patients' attitude, preparation and self-efficacy regarding ACP might enhance the quality of EOL care [13][14][15]. Hence, it is crucial for healthcare teams to provide appropriate EOL care by respecting patients' autonomy regarding medical decisions in light of their impending incompetency.…”

“…In Spain, although patients undergoing HD preferred to refrain from aggressive treatment during their final stage of illness, only 7.9% of patients completed ADs [28]; furthermore, 95% had little or no knowledge about cardiac resuscitation or mechanical ventilation and 22% believed that this decision should be made by their family members [29]. In addition, it has been found that HD patients' ACP decision-making is associated with factors such as age [30][31][32], education level [30,33], marital status [30,34], religious beliefs [35], health status or comorbidities [33], duration of HD [13], and frequency of hospitalisation [36].…”

When Patients Make Unexpected Medical Choices

“…7 A retrospective study among patients with ESRD receiving hemodialysis highlighted the underutilization of hospice care in this patient population. 8 The study also found that those patients who were aged > 75 years, had poor functional status, and had dialysis-related complications, such as sepsis and anemia, were more likely to elect withdrawal of hemodialysis. There was no difference in overall survival or quality of life among patients who were aged ≥ 75 years with multiple comorbidities and functional impairment who elected conservative management vs those who started dialysis.…”

“…There was no difference in overall survival or quality of life among patients who were aged ≥ 75 years with multiple comorbidities and functional impairment who elected conservative management vs those who started dialysis. 8 Long-term continuous dialysis has been associated with a lower quality of life, increased dependence on others, and a variety of symptoms, such as pain, nausea, insomnia, anxiety, or depression. 9…”

Hospice Care Improves Patients’ Self-Decision Making and Reduces Aggressiveness of End-of-Life Care for Advanced Cancer Patients

“…Ten years later, the Legislative Yuan in Taiwan had promulgated the Hospice Palliative Care Regulation, the law of safeguarding the terminal patients’ rights to choose “rejection of cardiopulmonary resuscitation” and life-sustaining treatments by signing a do-not-resuscitate order after two disease-related specialists confirm their terminal condition [ 25 , 26 ]. Taiwan is the first nation in Asia to formally and legally protect the rights to choose [ 27 ]. In these and the following years, hospice home care and hospice shared care became available in 1996 and 2011 [ 28 ], and their utilization increased markedly over the past 20 years [ 24 ].…”