BYWATER L1, DOUGLASS-MALLOY H1,3, ROBERTS M1,2, MCMAHON L1,2, DUCHARLET K1,2
1Eastern Health Integrated Renal Services, Box Hill, Australia, 2Eastern Health Clinical School, Monash University, Box Hill, Australia, 3Supportive and Palliative Care Service, Eastern Health, Box Hill, Australia
Background: Patients on maintenance dialysis are accepted at an older age with greater comorbidity, adding to treatment complexity. Therefore, discussing treatment burden and goals of care (GOC) are important considerations.
Aim: Identify mortality risk factors that prompt GOC discussions.
Methods: Dialysis patients, cared for at Eastern Health, who died between 1/1/2016-31/12/2019 were retrospectively analysed using Fischer’s exact tests to identify psychosocial variables associated with functional decline and mortality.
Results: Of the 113 patients identified, mean age 75 (SD 10yrs), dialysis vintage 5 years, with 3.7 admissions within 12 months preceding death. The mean Charleston comorbidity index (CCI) was 9.8 (SD 2.4) with cardiac failure (57%), IHD (55%), malignancy (35%), peripheral vascular disease (37%) and cognitive impairment (25%) predominant comorbidities. One quarter (27%) of patients lived in residential care, 75% used gait aids, and 49% needed assisted transport to dialysis. Median time between needing transport and death was 1.5 years [IQR0.6,2.4].
GOC discussion in the preceding twelve months was documented in 75 (66%) patients, either in renal clinics (53%), during dialysis (13%) or at penultimate admission (10%). Discussions were more likely if patients had high comorbidity burden (CCI>8 v CCI<8, 55%v10%, p< 0.05) or cardiac failure (41%v17%, p<0.05). No association was observed between GOC discussions and patient age, dialysis vintage, transport requirements, or other comorbidities.
Advance care plans (ACP), completed in 28 patients (25%), were more likely if a GOC discussion had already transpired (24%v3%, p<0.05) or a patient lived in residential care (15%v11%, p<0.05).
Conclusion: Patients usually died with significant comorbidities and functional dependency. Multiple comorbidities or cardiac failure prompted clinicians to discuss and document treatment planning to assist end of life care.
Laura is a final year renal advanced trainee. Her interest include Transplant nephrology, Immunology and renal supportive care