Infrequent Provision of Palliative Care to Patients with Dialysis-Requiring AKI

Abstract

Background and objectives: The use of palliative care in AKI is not well described. We sought to better understand palliative care practice patterns for hospitalized patients with AKI requiring dialysis in the United States.

Design, setting, participants, & measurements: Using the 2012 National Inpatient Sample, we identified patients with AKI and palliative care encounters using validated International Classification of Diseases, Ninth Revision, Clinical Modification codes. We compared palliative care encounters in patients with AKI requiring dialysis, patients with AKI not requiring dialysis, and patients without AKI. We described the provision of palliative care in patients with AKI requiring dialysis and compared the frequency of palliative care encounters for patients with AKI requiring dialysis with that for patients with other illnesses with similarly poor prognoses. We used logistic regression to determine factors associated with the provision of palliative care, adjusting for demographics, hospital-level variables, and patient comorbidities.

Results: We identified 3,031,036 patients with AKI, of whom 91,850 (3%) received dialysis. We observed significant patient- and hospital-level differences in the provision of palliative care for patients with AKI requiring dialysis; adjusted odds were 26% (95% confidence interval, 12% to 38%) lower in blacks and 23% (95% confidence interval, 3% to 39%) lower in Hispanics relative to whites. Lower provision of palliative care was observed for rural and urban nonteaching hospitals relative to urban teaching hospitals, small and medium hospitals relative to large hospitals, and hospitals in the Northeast compared with the South. After adjusting for age and sex, there was low utilization of palliative care services for patients with AKI requiring dialysis (8%)-comparable with rates of utilization by patients with other illnesses with poor prognosis, including cardiogenic shock (9%), intracranial hemorrhage (10%), and acute respiratory distress syndrome (10%).

Conclusions: The provision of palliative care varied widely by patient and facility characteristics. Palliative care was infrequently used in hospitalized patients with AKI requiring dialysis, despite its poor prognosis and the regular application of life-sustaining therapy.

Keywords: Acute Kidney Injury; African Continental Ancestry Group; Comorbidity; Demography; Fluid Therapy; Hispanic Americans; Humans; Inpatients; International Classification of Diseases; Intracranial Hemorrhages; Logistic Models; Palliative Care; Prognosis; Respiratory Distress Syndrome, Adult; Shock, Cardiogenic; United States; acute renal failure; clinical epidemiology; renal dialysis.

Figure 1.

Cohort of patients with and without AKI identified for the study using the defined inclusion and exclusion criteria.

Figure 2.

Multiple factors are associated with the provision of palliative care in patients with AKI requiring dialysis. Factors included in the figure were identified via backward stepwise selection from the characteristics shown in Table 1. Odds ratios (ORs) and 95% confidence intervals (95% CIs) reflecting the magnitudes of these associations are shown; 95% CIs that do not cross one denote statistical significance.