An aging ESRD population with complex medical issues demands our attention. As nephrologists, we must seek to discover the best ways to achieve quality care and quality of life for these individuals and their families within a cost-constrained health care environment.
Older adults with ESRD have the option of withholding dialysis or withdrawing from dialysis when the burden outweighs the potential benefits. In these situations hospice care is one intervention that supports quality care, quality of life, and reduced health care costs through symptom management, spiritual and psychosocial support, and avoidance of unnecessary hospitalizations. Hospice care, however, continues to be underutilized owing to several barriers such as lack of education in hospice care and ineffective training regarding advance care planning that includes preferences for end-of-life (EOL) care (1, 2). The percentage of Medicare beneficiaries receiving hospice care at the time of death has increased over the past decade, but opportunities for improvement in EOL care remain, including improvement in timely referral for hospice care.
As supported by epidemiological data, most patients receive hospice services only after discontinuing dialysis treatments. From 2004 to 2013, use of hospice care increased from 59% to 82% in those discontinuing dialysis and from 5% to 8% among those who did not discontinue dialysis (3). Evidence has indicated that many individuals with ESRD die in the hospital, which is not only costly but often is incongruent with the person’s wishes for EOL care. Advance care planning, in which health care professionals, patients, and families engage in shared decision-making that considers what matters most to the person living with ESRD, can facilitate greater hospice utilization and avoid costly hospitalization (4). Initiating hospice care earlier may allow death to occur in the person’s place of choice.
Saran R, et al.. US Renal Data System 2016 Annual Data Report: Epidemiology of kidney disease in the United States. Am J Kidney Dis 2017; 69 (suppl 1):S1–S688.
Schmidt RJ, Weaner BB, Long D. The power of advance care planning in promoting hospice and out-of-hospital death in a dialysis unit. J Palliative Med 2015; 18:62–66.