Hospice Care Improves End-of-Life Care for Patients who Stop Dialysis

October 15, 2019
Kenny Walter

Kenny Walter is an editor with HCPLive. Prior to joining MJH Life Sciences in 2019, he worked as a digital reporter covering nanotechnology, life sciences, material science and more with R&D Magazine. He graduated with a degree in journalism from Temple University in 2008 and began his career as a local reporter for a chain of weekly newspapers based on the Jersey shore. When not working, he enjoys going to the beach and enjoying the shore in the summer and watching North Carolina Tar Heel basketball in the winter.

The results of a new survey regarding quality of care for end stage renal disease patients raise questions about how to improve the quality of end-of-life care.

In a new patient survey, family members of patients with end-stage renal disease that are better informed about their end-of-life decisions rate report a higher quality of care.

In the 3369-patient survey, led by Claire A. Richards, PhD, University of Washington, investigators found that patients preparing for end-of-life decisions, improving access to concurrent receipt of dialysis and hospice services aids in improving the quality of end-of-life care for patients undergoing dialysis for end-stage renal disease.

Each patient that participated in the study was treated with maintenance dialysis at 111 US Department of Veterans Affairs medical centers and died between 2009-2015. The mean age of death for the study’s population was 70.6 years.

Also, 98.5% of the study was male and 1701 patients, more than half, had a family member respond to the survey, dubbed the Bereaved Family Survey.

Overall, 937 patients (27.8%) stopped dialysis prior to death, while 2432 patients (72.2%) continued dialysis treatment until death.

“Patients who stopped dialysis were more likely to have been receiving hospice services at the time of death than patients who continued dialysis (544 patients [58.1%] vs 430 patients [17.7%]),” the authors said.

The investigators surveyed family members of patients with end-stage renal disease who were undergoing maintenance dialysis, the adjusted predicted probability of family rating the quality of end-of-life care as excellent was higher for patients who stopped dialysis prior to death (54.9%) than for patients who did not stop dialysis (45.9%).

They also found that patients who did not stop dialysis, receipt of hospice was linked to a higher probability of the patient’s family rating the quality of end-of-life care as excellent (60.5% vs. 40.0%).

“In adjusted analyses, families were more likely to rate overall quality of end-of-life care as excellent if the patient had stopped dialysis (54.9% vs 45.9%; risk difference, 9.0% [95% CI, 3.3-14.8%]; P&thinsp;=&thinsp;.002) or continued to receive dialysis but also received hospice services (60.5% vs 40.0%; risk difference, 20.5% [95% CI, 12.2-28.9%]; P&thinsp;<&thinsp;.001),” the authors wrote.

The findings raise questions as to whether reducing barriers to hospice enrollment for those receiving dialysis could help improve the quality of end-of-life care among patients with end stage renal disease.

In the US, there are about 500,000 patients currently receiving maintenance dialysis for treatment of end-stage renal disease.

According to the investigators, approximately 25% of patients receiving maintenance dialysis for end-stage renal disease eventually halt treatment before death.

The study comes at an opportune time for those suffering from end-stage renal disease as the US Food and Drug Administration (FDA) approved canagliflozin (INVOKANA) last month for the reduction of end-stage kidney disease and cardiovascular events in patients with both type 2 diabetes and chronic kidney disease (CKD).

With the approval, canagliflozin becomes the first drug indicated for diabetic kidney disease in almost 2 decades.

The approval, granted to Janssen Pharmaceutical, was based on the results of the landmark phase 3 CREDENCE trial. The study results, published in April of this year, showed the oral therapy was associated with a 30% reduction in risk to progression of end-stage kidney disease, doubling of serum creatinine, and renal or cardiovascular death among patients with CKD and type 2 diabetes, compared to placebo.

The double-blind study, which included 4401 patients, showed the drug—along with standard care—was associated with a 32% reduction in end-stage kidney disease alone (HR, 0.68; (95% CI, 0.54 — 0.86; P = .0015). Canagliflozin also reduced risk of cardiovascular death and hospitalization for heart failure by 31% (HR, 0.69; 95% CI, 0.57 — 0.83; P = .0001) and major cardiovascular events (MACE) by 20% (HR, 0.80; 95% CI, 0.67 — 0.95; P = .0121).

The study, “Association of Family Ratings of Quality of End-of-Life Care With Stopping Dialysis Treatment and Receipt of Hospice Services,” was published online in JAMA Network Open.