End of Life, Withdrawal, and Palliative Care Utilization among Patients Receiving Maintenance Hemodialysis Therapy

Abstract

Background and objectives: Withdrawal from maintenance hemodialysis before death has become more common because of high disease and treatment burden. The study objective was to identify patient factors and examine the terminal course associated with hemodialysis withdrawal, and assess patterns of palliative care involvement before death among patients on maintenance hemodialysis.

Design, setting, participants, & measurements: We designed an observational cohort study of adult patients on incident hemodialysis in a midwestern United States tertiary center, from January 2001 to November 2013, with death events through to November 2015. Logistic regression models evaluated associations between patient characteristics and withdrawal status and palliative care service utilization.

Results: Among 1226 patients, 536 died and 262 (49% of 536) withdrew. A random sample (10%; 52 out of 536) review of Death Notification Forms revealed 73% sensitivity for withdrawal. Risk factors for withdrawal before death included older age, white race, palliative care consultation within 6 months, hospitalization within 30 days, cerebrovascular disease, and no coronary artery disease. Most withdrawal decisions were made by patients (60%) or a family member (33%; surrogates). The majority withdrew either because of acute medical complications (51%) or failure to thrive/frailty (22%). After withdrawal, median time to death was 7 days (interquartile range, 4-11). In-hospital deaths were less common in the withdrawal group (34% versus 46% nonwithdrawal, P=0.003). A third (34%; 90 out of 262) of those that withdrew received palliative care services. Palliative care consultation in the withdrawal group was associated with longer hemodialysis duration (odds ratio, 1.19 per year; 95% confidence interval, 1.10 to 1.3; P<0.001), hospitalization within 30 days of death (odds ratio, 5.78; 95% confidence interval, 2.62 to 12.73; P<0.001), and death in hospital (odds ratio, 1.92; 95% confidence interval, 1.13 to 3.27; P=0.02).

Conclusions: In this single-center study, the rate of hemodialysis withdrawals were twice the frequency previously described. Acute medical complications and frailty appeared to be driving factors. However, palliative care services were used in only a minority of patients.

Keywords: Cohort Studies; Frailty; Hospital Mortality; Logistic Models; Referral and Consultation; Terminal Care; chronic hemodialysis; death notification form; diabetes; end stage kidney disease; geriatric medicine; geriatric nephrology; goals of care; healthcare power of attorney; hemodialysis withdrawal; hospice; hospitalization; intensive care unit; mortality; palliative care; palliative nephrology; risk factors.

Graphical abstract

Figure 1.

Acute medical complication was the most common reason for HD withdrawal. (A) Reasons for HD withdrawal before death on the basis of categories by Murphy et al. (22) (n=262). (B) Conditions contributing to acute medical and chronic debilitating HD withdrawal reasons. FTT, failure to thrive; WD, withdrawal.

Figure 2.

More patients on HD without withdrawal died in a hospital setting. Care settings at time of death by percentage in patients on HD with (n=262) and without (n=274) HD withdrawal before death. ICU, intensive care unit.

Figure 3.

Most patients on HD that withdrew died within the first two weeks. Patient survival in days after final dialysis session in patients on HD who withdrew from dialysis therapy and died (n=262).