Conservative Management and End-of-Life Care in an Australian Cohort with ESRD

Abstract

Background and objectives: We aimed to determine the proportion of patients who switched to dialysis after confirmed plans for conservative care and compare survival and end-of-life care among patients choosing conservative care with those initiating RRT.

Design, setting, participants, & measurements: A cohort study of 721 patients on incident dialysis, patients receiving transplants, and conservatively managed patients from 66 Australian renal units entered into the Patient Information about Options for Treatment Study from July 1 to September 30, 2009 were followed for 3 years. A two-sided binomial test assessed the proportion of patients who switched from conservative care to RRT. Cox regression, stratified by center and adjusted for patient and treatment characteristics, estimated factors associated with 3-year survival.

Results: In total, 102 of 721 patients planned for conservative care, and median age was 80 years old. Of these, 8% (95% confidence interval, 3% to 13%), switched to dialysis, predominantly for symptom management. Of 94 patients remaining on a conservative pathway, 18% were alive at 3 years. Of the total 721 patients, 247 (34%) died by study end. In multivariable analysis, factors associated with all-cause mortality included older age (hazard ratio, 1.55; 95% confidence interval, 1.36 to 1.77), baseline serum albumin <3.0 versus 3.7-5.4 g/dl (hazard ratio, 4.31; 95% confidence interval, 2.72 to 6.81), and management with conservative care compared with RRT (hazard ratio, 2.18; 95% confidence interval, 1.39 to 3.40). Of 247 deaths, patients managed with RRT were less likely to receive specialist palliative care (26% versus 57%; P<0.001), more likely to die in the hospital (66% versus 42%; P<0.001) than home or hospice, and more likely to receive palliative care only within the last week of life (42% versus 15%; P<0.001) than those managed conservatively.

Conclusions: Survival after 3 years of conservative management is common, with relatively few patients switching to dialysis. Specialist palliative care services are used more frequently and at an earlier time point for conservatively managed patients, a practice associated with better symptom management and quality of life.

Keywords: Australia; Cohort Studies; Death; Follow-Up Studies; Hospices; Humans; Kidney Failure, Chronic; Palliative Care; Renal Insufficiency, Chronic; Renal Replacement Therapy; Serum Albumin; Terminal Care; advance directives; hospices; kidney failure, chronic; palliative medicine; renal dialysis.

Figure 1.

Patient Information about Options for Treatment (PINOT) cohort participant flow chart.

Figure 2.

Time between palliative care utilization and death by initial treatment modality for 86 of 247 participants.