Article Figures & Data
Figures
- 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.
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.
Tables
- Table 1.
Characteristics of nursing home residents with ESRD, cancer, advanced chronic obstructive pulmonary disease (COPD), and advanced dementia in the year before death
Characteristic ESRD (n=30,716) Cancer Receiving Chemotherapy or Radiation (n=2286) Advanced COPD (n=17,560) Advanced Dementia (n=10,979) Age, yr 72±12 79±10 82±9 86±9 Time from nursing home admission, m 7 (4, 11) 8 (4, 11) 9 (5, 12) 11 (9, 12) Women, % 51 60 60 73 Race, % White 67 88 93 86 Black 29 11 6 12 Other 4 1 1 2 Cancer receiving chemotherapy or radiation, % 1 100 — — Advanced COPD, % 19 23 100 7 Advanced dementia, % 2 5 — 100 Impaired decision-making skills, % 30 35 40 99 Activities of Daily Living scorea 17±7 16±7 16±7 25±4 Continuous variables are presented as mean±SD, or median (interquartile range), as appropriate. Conditions were identified hierarchically, starting with ESRD, followed by cancer, dementia, and COPD. —, not applicable.
↵a The Activities of Daily Living score ranges from 0 to 28; higher scores indicate more functional limitations.
- Table 2.
Characteristics of patients with ESRD in the month before death, stratified by presence of surrogate and treatment-limiting directive
Characteristic No Surrogate or Treatment-Limiting Directive (n=18,783) Surrogate Alone (n=2581) Treatment-Limiting Directive Alone (n=6438) Surrogate and Treatment-Limiting Directive (n=2914) Age, yr 70±12 74±11 75±11 78±10 Time receiving dialysis, yr 3 (1, 6) 3 (1, 5) 3 (1, 5) 3 (1, 5) Time from nursing home admission, m 7 (3, 10) 8 (4, 11) 8 (4, 11) 8 (4, 11) Hemodialysis (versus peritoneal dialysis), % 98 98 98 97 Women, % 50 51 53 54 Race, % White 59 76 76 89 Black 37 21 20 9 Other 4 3 4 2 Hospital referral region spending, % Quintile 1 6 12 10 17 Quintile 2 14 17 21 20 Quintile 3 18 21 19 23 Quintile 4 21 20 22 19 Quintile 5 41 30 29 21 Diabetes, % 86 83 82 80 Ischemic heart disease, % 82 84 83 83 Heart failure, % 90 90 90 91 Stroke, % 45 43 45 44 Chronic liver disease, % 27 22 22 19 Chronic lung disease, % 65 66 67 67 Cancer, % 26 28 27 28 Depression, % 45 50 50 50 Dementia, % 32 35 36 39 Impaired decision-making skills, % 27 31 36 37 Activities of Daily Living scorea 16±10 17±7 17±7 17±7 Days hospitalized in prior year 43 (23, 74) 37 (21, 65) 34 (18, 58) 29 (15, 50) Continuous variables are presented as mean±SD, or median (interquartile range), as appropriate.
↵a The Activities of Daily Living score ranges from 0 to 28; higher scores indicate more functional limitations.
- Table 3.
Association between treatment-limiting directive and surrogate decision-maker with treatments in the last month of life and site of death among patients with ESRD
Treatment Treatment-Limiting Directive Adjusted Risk Difference, % (95% CI) Surrogate Decision-Maker Adjusted Risk Difference, % (95% CI) Absent % (n=21,364) Present % (n=9352) Absent % (n=25,221) Present % (n=5495) Hospitalization 71 62 −7 (−8 to −6) 70 62 −4 (−6 to −3) Intensive care unit admission 47 32 −12 (−13 to −10) 44 34 −5 (−6 to −3) Mechanical ventilation 19 6 −10 (−11 to −9) 16 10 −2 (−3 to −1) CPR 6 2 −3 (−3 to −2) 5 3 −1 (−2 to 0) Gastrostomy tube 2 1 −1 (−1 to 0) 2 2 0 (0, 1) Inpatient death 46 34 −9 (−10 to −8) 44 35 −4 (−6 to −3) Hospice admission 23 33 5 (4 to 6) 25 31 1 (−1 to 2) Dialysis discontinuation 27 41 6 (5 to 7) 30 41 2 (1 to 3) Models 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, hospital referral region spending quintile, treatment-limiting directive, and surrogate decision-maker, in addition to correlation of subjects within nursing home facilities. 95% CI, 95% confidence interval; CPR, cardiopulmonary resuscitation.
- Table 4.
Frequency of discordant treatment among patients with ESRD who have a treatment-limiting directive
Type of Treatment Limitation Number of Patientsa Receiving Discordant Treatment, N (%) Do not resuscitate 8590 549 (6) Do not hospitalize 286 153 (54) Feeding restriction 1457 22 (2) Total patients with treatment-limiting directive 9352 707 (8) ↵a Patients may have more than one requested treatment limitation.
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