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Advance Directives and End-of-Life Care among Nursing Home Residents Receiving Maintenance Dialysis.
Clin J Am Soc Nephrol. 2017 Mar 07; 12(3):435-442.CJ

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.

Authors+Show Affiliations

Geriatric Research and Education Clinical Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, California; mktamura@stanford.edu. Division of Nephrology, Stanford University School of Medicine, Palo Alto, California.Division of Nephrology, Stanford University School of Medicine, Palo Alto, California.Department of Medicine, Group Health Cooperative, Seattle, Washington. Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington; and.Department of Medicine, Group Health Cooperative, Seattle, Washington. Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington; and.Department of Medicine, Group Health Cooperative, Seattle, Washington. Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington; and. Department of Hospital and Specialty Medicine, Veteran Affairs Puget Sound Health Care System, Seattle, Washington.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

28057703

Citation

Kurella Tamura, Manjula, et al. "Advance Directives and End-of-Life Care Among Nursing Home Residents Receiving Maintenance Dialysis." Clinical Journal of the American Society of Nephrology : CJASN, vol. 12, no. 3, 2017, pp. 435-442.
Kurella Tamura M, Montez-Rath ME, Hall YN, et al. Advance Directives and End-of-Life Care among Nursing Home Residents Receiving Maintenance Dialysis. Clin J Am Soc Nephrol. 2017;12(3):435-442.
Kurella Tamura, M., Montez-Rath, M. E., Hall, Y. N., Katz, R., & O'Hare, A. M. (2017). Advance Directives and End-of-Life Care among Nursing Home Residents Receiving Maintenance Dialysis. Clinical Journal of the American Society of Nephrology : CJASN, 12(3), 435-442. https://doi.org/10.2215/CJN.07510716
Kurella Tamura M, et al. Advance Directives and End-of-Life Care Among Nursing Home Residents Receiving Maintenance Dialysis. Clin J Am Soc Nephrol. 2017 Mar 7;12(3):435-442. PubMed PMID: 28057703.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Advance Directives and End-of-Life Care among Nursing Home Residents Receiving Maintenance Dialysis. AU - Kurella Tamura,Manjula, AU - Montez-Rath,Maria E, AU - Hall,Yoshio N, AU - Katz,Ronit, AU - O'Hare,Ann M, Y1 - 2017/01/05/ PY - 2016/07/13/received PY - 2016/10/28/accepted PY - 2017/1/7/pubmed PY - 2017/12/22/medline PY - 2017/1/7/entrez KW - ESRD KW - Medicare KW - United States KW - advance directives KW - dialysis KW - hospice care KW - hospices KW - hospitalization KW - humans KW - inpatients KW - intensive care units KW - kidney failure, chronic KW - nursing homes KW - prevalence KW - renal dialysis KW - terminal care SP - 435 EP - 442 JF - Clinical journal of the American Society of Nephrology : CJASN JO - Clin J Am Soc Nephrol VL - 12 IS - 3 N2 - 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. SN - 1555-905X UR - https://www.unboundmedicine.com/medline/citation/28057703/Advance_Directives_and_End_of_Life_Care_among_Nursing_Home_Residents_Receiving_Maintenance_Dialysis_ L2 - http://cjasn.asnjournals.org/cgi/pmidlookup?view=long&pmid=28057703 DB - PRIME DP - Unbound Medicine ER -