ASN Defends Access to Hospice Care, Dialysis Care

Patients can continue to access both end-of-life care in a hospice and receive dialysis care simultaneously, declared an August 6, 2014, ruling from the Centers for Medicare and Medicaid Services (CMS). ASN, led by the ASN Geriatric Nephrology Advisory Group (GNAG) and ASN Public Policy Board, had raised concerns to Medicare regarding its June proposal that could have inadvertently forced patients who are on dialysis and who want to enter hospice for another terminal illness and continue dialysis while they die to make a choice between the two services.

ASN’s advocacy efforts proved successful, and as a result the current policy as outlined in Chapter 11 of the Medicare Benefit Policy Manual will remain in place. Medicare acknowledged input from ASN and other stakeholder groups, stating in its final ruling: “If the patient’s terminal condition is not related to ESRD, the patient may receive covered services under both the ESRD benefit and the hospice benefit. Hospice agencies can provide hospice services to patients who wish to continue dialysis treatment.”

While acknowledging the need for CMS to prevent fraud and waste and to control healthcare costs—which was the original intent of the proposal that could have compromised simultaneous dialysis and hospice access—ASN highlighted that because dialysis can be a beneficial palliative treatment, Medicare should continue to allow patients with non-ESRD–related terminal diagnoses on dialysis to continue to receive services under both the ESRD benefit and the hospice benefit.

Patients with ESRD on dialysis have both a high mortality rate (an adjusted mortality rate of 6.4 to 7.8 times higher than the age-matched general population, with cardiovascular disease being the most common cause of death) and a high symptom burden. Compared with Medicare beneficiaries with other chronic conditions, older patients receiving long-term dialysis spend more time in the hospital and intensive care unit during the final month of life, are more likely to receive intensive procedures intended to prolong life, and are 1.5 to 2 times more likely to die in the hospital.

Consensus exists within the nephrology and palliative care communities that these patients need more, not less, access to palliative and hospice care, the society pointed out. In addition to others in the kidney community, ASN was joined in advocating for defense of hospice and dialysis care by the Coalition for Supportive Care of Kidney Patients and other stakeholders in the end-of-life and palliative care communities. The August Medicare ruling will preserve this access for the approximately 3000 patients currently receiving concurrent hospice and dialysis services.

Beyond voicing support for the role of dialysis in providing a comfortable end of life for end stage renal disease (ESRD) patients with unrelated terminal conditions, ASN also encouraged Medicare to explore the possibility of increasing access to hospice care for the broader population of patients with ESRD who have a life expectancy of less than six months who wish to receive these services. ASN recommended that CMS consider a demonstration project to test the feasibility, acceptability, and impact of concurrent receipt of hospice and dialysis services for patients without another terminal illness who wish to receive hospice care.

To read a complete copy of ASN’s comments to Medicare on this issue, please visit ASN’s policy website at