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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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    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.

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    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.

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    Table 1.

    Characteristics of nursing home residents with ESRD, cancer, advanced chronic obstructive pulmonary disease (COPD), and advanced dementia in the year before death

    CharacteristicESRD (n=30,716)Cancer Receiving Chemotherapy or Radiation (n=2286)Advanced COPD (n=17,560)Advanced Dementia (n=10,979)
    Age, yr72±1279±1082±986±9
    Time from nursing home admission, m7 (4, 11)8 (4, 11)9 (5, 12)11 (9, 12)
    Women, %51606073
    Race, %
     White67889386
     Black2911612
     Other4112
    Cancer receiving chemotherapy or radiation, %1100——
    Advanced COPD, %19231007
    Advanced dementia, %25—100
    Impaired decision-making skills, %30354099
    Activities of Daily Living scorea17±716±716±725±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.

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    Table 2.

    Characteristics of patients with ESRD in the month before death, stratified by presence of surrogate and treatment-limiting directive

    CharacteristicNo 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, yr70±1274±1175±1178±10
    Time receiving dialysis, yr3 (1, 6)3 (1, 5)3 (1, 5)3 (1, 5)
    Time from nursing home admission, m7 (3, 10)8 (4, 11)8 (4, 11)8 (4, 11)
    Hemodialysis (versus peritoneal dialysis), % 98989897
    Women, %50515354
    Race, %
     White59767689
     Black3721209
     Other4342
    Hospital referral region spending, %
     Quintile 16121017
     Quintile 214172120
     Quintile 318211923
     Quintile 421202219
     Quintile 541302921
    Diabetes, %86838280
    Ischemic heart disease, %82848383
    Heart failure, %90909091
    Stroke, %45434544
    Chronic liver disease, %27222219
    Chronic lung disease, %65666767
    Cancer, %26282728
    Depression, %45505050
    Dementia, %32353639
    Impaired decision-making skills, %27313637
    Activities of Daily Living scorea16±1017±717±717±7
    Days hospitalized in prior year43 (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.

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    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

    TreatmentTreatment-Limiting DirectiveAdjusted Risk Difference, % (95% CI)Surrogate Decision-MakerAdjusted Risk Difference, % (95% CI)
    Absent % (n=21,364)Present % (n=9352)Absent % (n=25,221)Present % (n=5495)
    Hospitalization7162−7 (−8 to −6)7062−4 (−6 to −3)
    Intensive care unit admission4732−12 (−13 to −10)4434−5 (−6 to −3)
    Mechanical ventilation196−10 (−11 to −9)1610−2 (−3 to −1)
    CPR62−3 (−3 to −2)53−1 (−2 to 0)
    Gastrostomy tube21−1 (−1 to 0)220 (0, 1)
    Inpatient death4634−9 (−10 to −8)4435−4 (−6 to −3)
    Hospice admission23335 (4 to 6)25311 (−1 to 2)
    Dialysis discontinuation27416 (5 to 7)30412 (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.

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    Table 4.

    Frequency of discordant treatment among patients with ESRD who have a treatment-limiting directive

    Type of Treatment LimitationNumber of PatientsaReceiving Discordant Treatment, N (%)
    Do not resuscitate8590549 (6)
    Do not hospitalize286153 (54)
    Feeding restriction145722 (2)
    Total patients with treatment-limiting directive9352707 (8)
    • ↵a Patients may have more than one requested treatment limitation.

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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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