End-of-Life Choice, Death with Dignity, Palliative Care and Counseling

Aggressive end-of-life care for Medicare dialysis patients is pervasiveby Jay


By Kevin B. O’Reilly
May 7, 2012

Patients on dialysis are subject to much more intensive medical care in the last month of life than are patients dying of cancer or heart failure, said an analysis of Medicare data that is raising concerns about the end-of-life care that patients with end-stage renal disease receive.

Nearly 80% of Medicare patients on dialysis were hospitalized in the 30 days before death and spent twice as many days in the hospital as patients dying of cancer, said a research letter published April 23 in Archives of Internal Medicine that was based on data from nearly 100,000 patients from the U.S. Renal Data System and Medicare between 2004 and 2009.

Nearly half of the patients on long-term dialysis were admitted to an intensive care unit in their final month, compared with about a quarter of cancer patients and a fifth of patients with heart failure. Three in 10 dialysis patients received intensive procedures such as mechanical ventilation, feeding tubes and cardiopulmonary resuscitation — a rate three times higher than that of cancer patients, the study said. Only 20% of the kidney-failure patients were referred to hospice, compared with 40% of the patients dying of heart failure and 55% of cancer patients.

“It’s really a shame that these elderly patients go through such intensive, aggressive treatment, and I’m sure they suffered more because of that rather than being comfortable and dying at home,” said Alvin H. Moss, MD, a Morgantown, W.Va., nephrologist and palliative medicine physician who did not participate in the study.

“This is really distressing,” said Dr. Moss, who helped write the clinical guideline on starting and stopping dialysis for the 4,000-member Renal Physicians Assn. “The hospice use by these elderly patients is less than half the national average, which is 45% now. The hospice use for cancer patients is above the national average, and people are more accepting of the fact that cancer patients might be referred to hospice. What most people don’t realize is that most dialysis patients are sicker than cancer patients.”

The dialysis guideline says physicians should conduct advance care planning and not use dialysis for patients with no decision-making capacity. Nephrologists should “consider forgoing dialysis” for patients with end-stage renal disease who are 75 or older and have many serious co-morbidities, significantly impaired functional status or severe chronic malnutrition, the guideline says.

Poor odds for elderly on dialysis

Survey data show that about 75% of patients do not want to die in the hospital or ICU, said Dr. Moss, professor of medicine at West Virginia University School of Medicine and director of the university’s Center for Health Ethics & Law. Nearly half of the dialysis patients died in the hospital, the Archives study found.
Decisions to continue dialysis in elderly patients with end-stage renal disease appear to be at odds with patients’ general end-of-life care wishes, said Susan P.Y. Wong, MD, lead author of the study.

“We need to take a step back and look at the care that we provide to older patients on chronic dialysis at the end of life, and look at what our motivations are and whether our practices are consistent with their preferences,” said Dr. Wong, a resident at the University of Washington School of Medicine in Seattle who will begin her nephrology fellowship in July. “The data would suggest that perhaps the way in which we are providing end-of-life care to this very vulnerable population might be more provider-driven than patient-driven.”

Among patients 75 and older, the five-year survival rate for patients on dialysis is 15%, according to research cited in an invited commentary that appeared in response to Dr. Wong’s study.

“The practice pattern and incentives are to automatically initiate dialysis therapy, and from there to treat all the complications, without giving patients the opportunity to anticipate what they might otherwise want,” said Kevin A. Schulman, MD, co-author of the commentary. “Patients need an opportunity to have this conversation, and it needs to be very formal and documented.”

Medicare pays for six educational sessions for patients before they start dialysis, but these sessions do not necessarily have to cover advance care planning. Requiring completion of such documentation could help improve end-of-life care for patients with end-stage renal disease, said Dr. Schulman, associate director of the Duke University School of Medicine’s Clinical Research Institute in Durham, N.C.

Even the decision to start dialysis is fraught, Dr. Wong said. Dialysis can consist of six-hour sessions four days a week and is physiologically and psychologically draining. Most elderly patients will not qualify for a kidney transplant or will not live long enough for one to become available.

“What I think is unfortunate is to make this a black-and-white decision, that if you don’t do dialysis, you’re going to die,” Dr. Wong said. “It’s more complicated than that.”