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

Manjula Kurella Tamura, Maria E. Montez-Rath, Yoshio N. Hall, Ronit Katz and Ann M. O’Hare
CJASN March 2017, 12 (3) 435-442; DOI: https://doi.org/10.2215/CJN.07510716
Manjula Kurella Tamura
*Geriatric Research and Education Clinical Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, California;
†Division of Nephrology, Stanford University School of Medicine, Palo Alto, California;
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Maria E. Montez-Rath
†Division of Nephrology, Stanford University School of Medicine, Palo Alto, California;
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Yoshio N. Hall
‡Department of Medicine, Group Health Cooperative, Seattle, Washington;
§Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington; and
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Ronit Katz
‡Department of Medicine, Group Health Cooperative, Seattle, Washington;
§Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington; and
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Ann M. O’Hare
‡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
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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.

  • dialysis
  • ESRD
  • advance directives
  • hospice care
  • hospices
  • hospitalization
  • humans
  • inpatients
  • intensive care units
  • kidney failure, chronic
  • Medicare
  • nursing homes
  • prevalence
  • renal dialysis
  • terminal care
  • United States
  • Received July 13, 2016.
  • Accepted October 28, 2016.
  • Copyright © 2017 by the American Society of Nephrology
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Clinical Journal of the American Society of Nephrology: 12 (3)
Clinical Journal of the American Society of Nephrology
Vol. 12, Issue 3
March 07, 2017
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Advance Directives and End-of-Life Care among Nursing Home Residents Receiving Maintenance Dialysis
Manjula Kurella Tamura, Maria E. Montez-Rath, Yoshio N. Hall, Ronit Katz, Ann M. O’Hare
CJASN Mar 2017, 12 (3) 435-442; DOI: 10.2215/CJN.07510716

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Advance Directives and End-of-Life Care among Nursing Home Residents Receiving Maintenance Dialysis
Manjula Kurella Tamura, Maria E. Montez-Rath, Yoshio N. Hall, Ronit Katz, Ann M. O’Hare
CJASN Mar 2017, 12 (3) 435-442; DOI: 10.2215/CJN.07510716
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Keywords

  • dialysis
  • ESRD
  • Advance Directives
  • hospice care
  • Hospices
  • hospitalization
  • Humans
  • inpatients
  • intensive care units
  • Kidney Failure, Chronic
  • Medicare
  • Nursing Homes
  • prevalence
  • renal dialysis
  • terminal care
  • United States

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