Thursday, September 7, 2006

Dialysis and hospice

There's an interesting article in the Clinical Journal of the American Society of Nephrology about hospice use by dialysis patients in the US. It relies on data collected nationally for all U.S. dialysis patients (USRDS & CMMS data) and looks at hospice use amongst dialysis patients who died in 2001 & 2002. It provides a helpful snapshot of end of life circumstances in this population. Hospice use was relatively rare: 14% of deaths overall. 22% of patients died after withdrawal of dialysis; of these 42% used hospice services**. Not surprisingly hospice use was associated with older age, white race, and lower Medicare costs in the last weeks and months of life. What was most interesting to me however was the broad geographic disparity in hospice use: the extremes were 56% of patients dying after dialysis withdrawal in Iowa used hospice compared to 17% in Maine. This disparity was not associated with state hospice density (number of hospices per population) which suggests it is not a disparity in access to hospice but in physician practice regarding hospice referral. I'm not going to speculate as to why some regions did 'better' than others; this extreme variation in practice however is a quality red flag suggesting major problems.

(For those that are interested August's Journal of Palliative Medicine has a comprehensive review of end stage renal disease and palliative care.)

**About 3% of the patients died on hospice without dialysis withdrawal indicating that this practice, while rare, does occur. The authors suggest it's so rare because people don't realize that patients can get hospice care while still receiving dialysis if their terminal diagnosis in non-renal. In my experience this is not the case--the issue is that for dialysis patients who are dying of something else, when the time comes that people are considering hospice care, they are usually so ill that continuing dialysis is impractical--the patient is bedbound or too unstable medically to be transported to and from dialysis centers. Continuing dialysis in these moribund patients just becomes a non-issue.

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