1. Among patients undergoing maintenance dialysis, nearly half of patients valued comfort-focused care over life-prolonging care if they were to become seriously ill.
2. Patients who valued comfort-focused care were modestly associated with a greater probability of engagement in advance care planning but still received intensive care at the end of life, similar to the patients who favoured longevity-focused care.
Evidence Rating Level: 2 (Good)
Study Rundown: Patients undergoing maintenance dialysis are more likely to receive intensive care and die in hospital compared to other populations with serious illnesses. Despite these trends, previous studies have shown that patients treated with dialysis value care that preserves the quality of life over prolonging life. This survey study evaluated patients’ values surrounding goals of care and whether these preferences were associated with self-reported engagement in advance care planning (ACP) and end-of-life (EOL) care as per registry and insurance data. Among 933 patients, nearly half of the respondents valued comfort-focused care over longevity-focused care. However, the two groups had no substantial differences in involvement in different aspects of ACP and EOL care. At follow-up, most deceased patients received intensive end-of-life care (hospitalization, intensive procedures, no discontinuation of dialysis, no hospice care) regardless of their values indicated in the survey. A limitation of this study was that only one survey questionnaire was used to categorize patients’ values at one point in time. This method might not have elicited the nuances in patient’s goals of care, such as wishing to extend life but also focus on relieving pain and discomfort. In a healthcare system that defaults to life prolongation, it appears that patients treated with maintenance dialysis and favour comfort measures have inadequate ACP engagement and receive EOL that does not align with their values. As such, the clinical implication of this study highlights the difficulties in achieving comfort-focused care despite expressed patient wishes and possible areas for meaningful intervention.
Click to read the study in JAMA Internal Medicine
Relevant Reading: Persistent Gaps in Use of Advance Directives Among Nursing Home Residents Receiving Maintenance Dialysis
In-Depth [survey]: The study was conducted at 31 non-profit dialysis centers in Seattle, Washington and Nashville, Tennessee, from 2015 to 2018, with follow-up of deceased patients in 2020. This study included 933 patients (mean [SD] age, 62.6 [14.0] years; 525 males [56.3%]; 254 patients [27.2%] identified as Black) with advanced kidney disease on maintenance dialysis. Of these patients, 452 (48.4%) valued comfort-focused care, 179 (19.2%) valued longevity-focused care, and 302 (32.4%) were unsure of the level of care that they would value. Through logistic regression models, the estimated probability of advance care planning was compared between the comfort-focused and longevity-focused groups. The comfort-focused group had greater estimated probabilities of completing an advanced directive 47.5% [95% CI, 42.9%-52.1%] vs 28.1% [95% CI, 24.0%-32.3%] longevity-focused or unsure (P < .001); discussing hospice 28.6% [95% CI, 24.6%-32.9%] vs 18.2% [95% CI, 14.7%-21.7%] longevity-focused or unsure (P < .001); discussing discontinuation of dialysis 33.3% [95% CI, 29.0%-37.7%] vs 21.9% [95% CI, 18.2%-25.8%] longevity-focused or unsure (P < .001). The longevity-focused group had a greater estimated probability of wishing to receive cardiopulmonary resuscitation and mechanical ventilation. There were no statistically significant differences between the groups for the following outcomes evaluated at follow-up: receiving an intensive procedure during the final month of life, discontinued dialysis, and hospital enrollment.
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