Few Patients With ESRD Receive Hospice Care

Pam Harrison

May 01, 2018

Only a small proportion of patients with end-stage renal disease (ESRD) on maintenance hemodialysis receive hospice care at the end of life, and almost half of those who do receive it enter hospice care within 3 days of their death, new data show.

Moreover, patients with ESRD admitted to hospice have higher hospitalization and intensive care unit admission rates in the last week of life compared with patients who do not receive hospice care. The analysis shows, however, that Medicare costs do not differ substantially between those who do and those who do not receive hospice.

"While these patterns of utilization and costs may seem counterintuitive, they likely reflect a crisis-driven approach to hospice referral in which hospice serves as a last-minute 'add on' to the intensive and costly patterns of end-of-life care previously described for members of this population," Melissa Wachterman, MD, MPH, from the Veterans Affairs Boston Healthcare System in Massachusetts and colleagues write.

"Our findings also suggest that as long as close to half of hospice referrals occur within the last 3 days of life, efforts to promote hospice utilization in patients receiving maintenance hemodialysis are unlikely to have a significant effect on end-of-life costs and health care utilization," they conclude.

The authors and other experts note that the limited use of dialysis in this patient population likely stems in part from Medicare policies that restrict simultaneous receipt of active treatment and hospice care. The policy should be reconsidered, they say.

The cross-sectional study, published online April 30 in JAMA Internal Medicine, included 770,191 patients receiving hemodialysis enrolled in the US Renal Data System registry.

All participants were Medicare beneficiaries who died between 2000 and 2014. The mean age of the cohort was 74.8 years and 53.7% were men.

Of this large cohort of patients, only 20% were receiving hospice care at the time of their death.

Among those who received hospice, only about one-fifth of in hospice received care for more than 2 weeks.

Table. Duration of Hospice Care Before Death in Patients With ESRD

Duration Patients, %
3 days or fewer 41.5
4 to 7 days 22.5
8 to 14 days 14.3
15 days or more 21.7

Hospital admission rates were highest for patients with ESRD admitted to hospice for 3 days or fewer, at 83.6% compared with 74.4% for those who did not receive hospice care and 35.1% for those who were in hospice care for 15 days or longer. Similarly, intensive care unit admissions in the last month of life were highest among those admitted to hospice for 3 or fewer days, at 54.0% vs 51.0% of those who had no hospice care and 16.7% of patients who were in hospice care for 15 days and longer.

Any duration of hospice care did seem to reduce the risk of dying in the hospital or late intensive procedures, however. Overall, 55.1% of patients who did not receive hospice services died in hospital compared with 13.5% of those who spent 3 or fewer days in hospice and less than 5% of patients who spent the longest time in hospice care. Similarly, 31.6% of patients who were not involved in hospice underwent an intensive procedure before their death compared with 17.7% of patients who spent the shortest amount of time in hospice and 3.0% for those in hospice 15 days or longer.

Finally, mean Medicare costs for patients who spent 3 days or less in hospice were virtually identical to those for patients not involved in hospice care ($10,756 vs $10,871).

In contrast, "Medicare costs and rates of all utilization measures decreased with increasing lengths of stay beyond 3 days," researchers note.

Stop Treatment

As investigators explain, patients enrolled in fee-for-service Medicare are required to stop any form of "disease-modifying" treatment for the condition for which they are admitted to hospice care. "In instances where [ESRD] is viewed as the life-limiting condition, patients cannot receive concurrent Medicare coverage for hospice and hemodialysis," the study authors elaborate. Thus, this policy effectively forces patients to choose between discontinuing dialysis, a disarming prospect because patients can expect to live only about a week after stopping treatment, and opting for hospice services knowing they have less than a week to live.

This explains why in the current study, almost two thirds of those who died in hospice had discontinued hemodialysis compared with about 14% of those who did not die in hospice, Wachterman and colleagues observe. Moreover, those receiving hemodialysis are less likely to be referred to hospice than patients with more hospice-compatible conditions such as cancer or dementia. This observation is supported by an earlier study by Wachterman and colleagues, in which patients with ESRD, cardiopulmonary failure, or frailty were much less likely to die in hospice care compared with patients with cancer or dementia.

"Hospice utilization at the end of life for Medicare beneficiaries with ESRD who had been treated with maintenance hemodialysis increased markedly between 2000 and 2014," Wachterman and colleagues observe. "However, there was little change during this time in hospice length of stay for members of this population."

Palliative care rates are also low in the ESRD population, the authors note. "Concurrent receipt of hemodialysis and palliative care services earlier in the illness trajectory could perhaps also allow for a smoother, less crisis-driven transition to hospice closer to the end of life," they state.

Reconsider Policy

In an accompanying editorial, Margaret Schwarze, MD, and colleagues from the University of Wisconsin in Madison ask whether the policy requiring patients with ESRD to discontinue hemodialysis should be reconsidered. "Discontinuation of hemodialysis requires an active decision to withdraw life-sustaining treatment, which for patients with ESRD is likely a significant barrier to hospice enrollment," Schwarze and colleagues write. "Given that dialysis termination has a well-defined and quite limited survival, patients and their family members may struggle with the decision to essentially 'choose their own death,' " they add. One solution might be to change hospice benefits that would allow patients with end-of-life ESRD to continue to receive hemodialysis and hospice care.

"[This] could be both cost saving and improve their care at the end of life," the editorialists suggest. They also support introduction of palliative care even on initiation of hemodialysis as a way to promote "goal-concordant treatment decisions" that would help patients address their end-of-life needs as their health deteriorates over time.

"This in combination with policy modifications that permit patients whose terminal illness is ESRD to maintain coverage for hemodialysis, along with their hospice benefit, has potential to expand access to hospice, improve end-of-life care, and reduce costs," the editorialists conclude.

Schwarze is supported by a grant from the National Palliative Care Research Center. The authors and other editorialists have disclosed no relevant financial relationships.

JAMA Intern Med. Published online April 30, 2018. Article abstract, Editorial extract

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