The power of advance care planning in promoting hospice and out-of-hospital death in a dialysis unit.

BACKGROUND: Despite mortality rates that exceed those of most cancers, hospice remains underutilized in patients with end-stage renal disease (ESRD) on dialysis and nearly half of all dialysis patients die in the hospital. OBJECTIVE: To review the impact of advance care planning on withdrawal from dialysis, use of hospice, and location of death. DESIGN: Retrospective review. SETTING: A rural outpatient dialysis unit. PARTICIPANTS: Former dialysis patients who died over a 5-year period. EXPOSURE: Advance care planning, the use of physician orders for life-sustaining therapy program (POLST). MAIN OUTCOME AND MEASURE: Use of hospice among patients withdrawing from dialysis, location of death. RESULTS: Advance care planning was associated with a low incidence of in-hospital death and among those who withdrew, a high use of hospice. CONCLUSIONS AND RELEVANCE: Comprehensive and systematic advance care planning among patients with ESRD on dialysis promotes greater hospice utilization and may facilitate the chance that death will occur out of hospital.

Utility of the "surprise" question to identify dialysis patients with high mortality.

BACKGROUND AND OBJECTIVES: Dialysis patients are increasingly characterized by older age, multiple comorbidities, and shortened life expectancy. This study investigated whether the "surprise" question, "Would I be surprised if this patient died in the next year?" identifies patients who are at high risk for early mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This prospective cohort study of 147 patients in three hemodialysis dialysis units classified patients into "yes" and "no" groups on the basis of the "surprise" question response and tracked patient status (alive or dead) at 12 mo. Demographics, Charlson Comorbidity Index score, and Karnofsky Performance Status score were measured. RESULTS: Initially, 34 (23%) patients were classified in the "no" group. Compared with the 113 patients in the "yes" group, the patients in the "no" group were older (72.5 +/- 12.8 versus 64.5 +/- 14.9), had a higher comorbidity score (7.1 +/- 2.3 versus 5.8 +/- 2.1), and had a lower performance status score (69.7 +/- 17.1 versus 81.6 +/- 15.8). At 12 mo, 22 (15%) patients had died; the mortality rate for the "no" group was 29.4% and for the "yes" group was 10.6%. The odds of dying within 1 yr for the patients in the "no" group were 3.5 times higher than for patients in the "yes" group, (odds ratio 3.507, 95% CI 1.356 to 9.067, P = 0.01). CONCLUSIONS: The "surprise" question is effective in identifying sicker dialysis patients who have a high risk for early mortality and should receive priority for palliative care interventions.