Douglass-Molloy H1,2, Bywater L1, McMahon L1,2, William L2,3,4, Ducharlet K1,3
1Eastern Health Integrated Renal Service, Melbourne, Australia, 2Eastern Health Supportive and Palliative Care Service, Melbourne, Australia, 3Eastern Health Clinical School, Monash University, Melbourne, Australia, 4Public Health Palliative Care Unit, La Trobe University, Melbourne, Australia
Aim: To investigate patterns of end-of-life care (EOLC) for dialysis patients.
Background: Maintenance dialysis conveys significant mortality and treatment burden, however, data describing the provision of end-of-life care is limited.
Methods: A retrospective cohort study reviewed electronic medical records for long-term adult dialysis patients cared for by Eastern Health Integrated Renal Service who died between 1/1/16-31/12/19.
Results: Over three years, 113 patients died. Mean age 74 years, 28% female and mean modified Charlson Comorbidity Index 9.8. The median duration of dialysis was 52 months [IQR 20,96]; haemodialysis (89%) and peritoneal dialysis (11%).
Death occurred at hospital (51%), hospice (17%), residential care (13%) and home (10%), and 55% of patients were referred to palliative care services. Regarding inpatients, dying was recognised and documented in 68% of patients two days (median) before death. An EOLC or revised goals of care discussion was held in 75%; usually initiated by the renal team (65%).
Planned dialysis withdrawal occurred for 49% of patients and occurred 8 days (median) before death [IQR 6,11]. Discussions of dialysis withdrawal were most commonly initiated and documented by the nephrology team; with median time between first conversation and last dialysis session of 0.5 days [IQR -2,18.75 ] and death 11.5 days [IQR 5,35]. The most prevalent symptoms patients experienced in the last 48 hours of life were drowsiness 56%, dyspnea 30%, pain 26% and agitation 27%.
Conclusions: Dialysis patients who die often have numerous comorbidities, are elderly, and well known to the nephrology team. These data highlight the importance of renal team engagement in caring for patients at end of life and reveals opportunities to improve end-of-life care for dialysis patients.
Dr Douglass-Molloy is an Australian palliative care advanced trainee with a keen interest in renal supportive care.