Advance directives outlining individuals' preferences related to
end-of-life care are often promoted for patients with serious illnesses
such as kidney failure as a means to avoid interventions that are
unwanted or of limited benefit. Little is known about the relation
between the content of advance directives and later treatment decisions
among kidney failure patients, however.
Many nursing home residents receiving
dialysis do not have advance directives that sufficiently address
end-of-life treatment decisions, indicated a new study. Those with advance directives that put
limitations on treatments and designated surrogate decision makers had
fewer hospitalizations, intensive procedures, and inpatient deaths, and
they were more likely to use hospice and discontinue dialysis prior to
‘Nearly all patients with an advance directive requesting treatment limitations received end-of-life care that was in line with their preferences.’
The study, which appears in an upcoming issue of the Clinical Journal of the American Society of Nephrology
(CJASN), found that nearly all patients with an advance directive
requesting treatment limitations received end-of-life care that was in
line with their preferences.
To investigate, Manjula Kurella Tamura, (VA Palo Alto Health
Care System and Stanford University) and her colleagues examined the
prevalence and content of advance directives among 30,716 nursing home
residents with end-stage renal disease (ESRD), and 30,825 nursing home
residents with other serious illnesses during the year before death. The
investigators also linked the content of advance directives to Medicare
claims to determine which treatments ESRD patients received in the last
month of life.
In the last year of life, 47% of patients with ESRD vs. 59%-70% of
patients with other serious illnesses had any form of advance directive.
In addition, 36% of nursing home residents with ESRD had a
treatment-limiting directive, 22% had a surrogate decision maker, and
13% had both. These estimates were 13%-27%, 5%-11%, and 6%-13% lower,
respectively, than for patients with other serious illnesses.
patients with ESRD who had both a treatment limiting directive and
surrogate decision maker, the frequencies of hospitalization, intensive
care unit admission, intensive procedures, and inpatient death were
lower by 13%, 17%, 13% and 14%, respectively, and hospice use and
dialysis discontinuation were 5% and 7% higher compared with patients
with ESRD who lacked both components.
"We found that advance directives indicating treatment limitations
and/or documenting surrogate decision makers were associated with less
intensive end-of-life care among nursing home residents with ESRD, but
these were in place much less often than for nursing home residents with
other serious illnesses," said Dr. Tamura.
"Because the vast majority
of patients with a treatment limiting directive received care that was
consistent with their advance directive, our findings suggest that
efforts to increase engagement in advance care planning and expand the
use of advance directives among patients receiving dialysis may offer
untapped opportunities to better align end-of-life care with patient
preferences and values."