Trends in Receipt of Intensive Procedures at the End of Life Among Patients Treated With Maintenance Dialysis

Abstract

Background Many dialysis patients receive intensive procedures intended to prolong life at the very end of life. However, little is known about trends over time in use of these procedures. We describe temporal trends in receipt of inpatient intensive procedures during the last six months of life among patients treated with maintenance dialysis. Study Design Mortality follow-back study. Setting & Participants 649,607 adult Medicare beneficiaries on maintenance dialysis who died in 2000–2012. Predictors Time period of death (2000–2003, 2004–2008, or 2009–2012), age at the time of death (18–59, 60–64, 65–69, 70–74, 75–79, 80–84 and ≥ 85 years) and race/ethnicity (Hispanic, non-Hispanic Black, or non-Hispanic White). Outcome Receipt of an inpatient intensive procedure (defined as invasive mechanical ventilation/intubation, tracheostomy, gastrostomy/jejunostomy tube insertion, enteral or parenteral nutrition, or cardiopulmonary resuscitation) during the last six months of life. Results Overall, 34% of cohort patients received an intensive procedure in the last six months of life, increasing from 29% in 2000 to 36% in 2012 (with 2000–2003 as the referent category, adjusted risk ratios [RRs] were 1.06 [95% CI, 1.05–1.07] and 1.10 [95% CI, 1.09–1.12] for 2004–2008 and 2009–2012, respectively). Use of intensive procedures increased more markedly over time in younger versus older patients (comparing 2009–2012 to 2000–2003, the adjusted RR was 1.18 [95% CI, 1.15–1.20] for the youngest age group, as opposed to 1.00 [95% CI, 0.96–1.04] for the oldest age group). Comparing 2009–2012 to 2000–2003, the use of intensive procedures increased more dramatically for Hispanic patients than for non-Hispanic Black or non-Hispanic White patients (adjusted RRs of 1.18 [95% CI, 1.14–1.22], 1.09 [95% CI, 1.07–1.11], and 1.10 [95% CI, 1.08–1.12], respectively). Limitations Data sources do not provide insight into reasons for observed trends in use of intensive procedures. Conclusions Among patients treated with maintenance dialysis, there is a trend toward more frequent use of intensive procedures at the end of life, especially in younger patients and those of Hispanic ethnicity.

Circumstances of Death among Undocumented Immigrants Who Rely on Emergency-Only Hemodialysis

“…Unexpected critical events are almost certainly related to the emergent presentation needed to secure treatment with hemodialysis for these patients (e.g., high potassium leading to cardiac death). Our findings are consistent with our prior research exploring the palliative needs of Latinos on hemodialysis (3) and national data documenting intensive patterns of end-of-life care among Latino patients on dialysis (4). How best to foster end-of-life planning for undocumented patients with ESKD receiving EOHD exposes the fundamental contradictions inherent in current approaches to caring for these patients.…”

Race, Ethnicity, and End-of-Life Care in Dialysis Patients in the United States

“…For example, one study reported that Hispanic patients on dialysis were more likely to undergo intensive medical procedures such as ventilation, tracheostomy, feeding enterostomy, and cardiopulmonary resuscitation in the last 6 months of life. 20 Other studies comparing black to white patients showed that in-hospital death, dialysis discontinuation, and hospice referral differed substantially between the two racial populations examined, as well as across regions of the United States. [21][22][23] Our study differs from these informative studies in a number of ways.…”

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

“…In a survey of patients with CKD in Canada, 36% preferred to die at home or in an inpatient hospice (29%) rather than in a hospital (27%) (10). This contrasts starkly with the current reality of end-of-life care for patients on dialysis, which is more aggressive than that for other life-limiting diseases (5,11,12).…”