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. 2017 Mar 7;12(3):435-442.
doi: 10.2215/CJN.07510716. Epub 2017 Jan 5.

Advance Directives and End-of-Life Care among Nursing Home Residents Receiving Maintenance Dialysis

Manjula Kurella Tamura  1   2 , Maria E Montez-Rath  2 , Yoshio N Hall  3   4 , Ronit Katz  3   4 , Ann M O'Hare  3   4   5
Affiliations

Advance Directives and End-of-Life Care among Nursing Home Residents Receiving Maintenance Dialysis

Manjula Kurella Tamura et al. Clin J Am Soc Nephrol. .

Abstract

Background and objectives: Little is known about the relation between the content of advance directives and downstream treatment decisions among patients receiving maintenance dialysis. In this study, we determined the prevalence of advance directives specifying treatment limitations and/or surrogate decision-makers in the last year of life and their association with end-of-life care among nursing home residents.

Design, setting, participants, & measurements: Using national data from 2006 to 2007, we compared the content of advance directives among 30,716 nursing home residents receiving dialysis to 30,825 nursing home residents with other serious illnesses during the year before death. Among patients receiving dialysis, we linked the content of advance directives to Medicare claims to ascertain site of death and treatment intensity in the last month of life.

Results: In the last year of life, 36% of nursing home residents receiving dialysis had a treatment-limiting directive, 22% had a surrogate decision-maker, and 13% had both in adjusted analyses. These estimates were 13%-27%, 5%-11%, and 6%-13% lower, respectively, than for decedents with other serious illnesses. For patients receiving dialysis who had both a treatment-limiting directive and surrogate decision-maker, the adjusted frequency 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 receiving dialysis lacking both components.

Conclusions: Among nursing home residents receiving dialysis, treatment-limiting directives and surrogates were associated with fewer intensive interventions and inpatient deaths, but were in place much less often than for nursing home residents with other serious illnesses.

Keywords: ESRD; Medicare; United States; advance directives; dialysis; hospice care; hospices; hospitalization; humans; inpatients; intensive care units; kidney failure, chronic; nursing homes; prevalence; renal dialysis; terminal care.

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Figures

Figure 1.
Figure 1.
Age-, sex-, and race-adjusted prevalence of advance directives in the last year of life among nursing home residents with ESRD, advanced chronic obstructive pulmonary disease (COPD), cancer, and advanced dementia. Error bars indicate 95% confidence intervals.
Figure 2.
Figure 2.
Adjusted risk difference in the frequency of treatments in the last month of life and site of death for patients with ESRD who have a treatment-limiting directive and/or surrogate decision-maker compared with patients with neither measure. Estimates are adjusted for age, sex, race, duration of dialysis, length of nursing home stay, days in hospital in prior year, dialysis modality, functional status, diabetes, ischemic heart disease, heart failure, stroke, chronic liver disease, chronic lung disease, cancer, depression, dementia, impaired decision-making skills, and hospital referral region spending quintile in addition to correlation of subjects within nursing home facilities. Error bars indicate 95% confidence intervals (95% CI). ICU, intensive care unit.
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