• WongSusan P YSPYHealth Service Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA. Electronic address: spywong@uw.edu., Margaret K Yu, Pamela K Green, Chuan-Fen Liu, Paul L Hebert, and Ann M O'Hare.
• Health Service Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA. Electronic address: spywong@uw.edu.
• Am. J. Kidney Dis. 2018 Jul 1; 72 (1): 42-49.

BackgroundLittle is known about patterns of end-of-life care for patients with advanced kidney disease not treated with maintenance dialysis.Study DesignCase series.Setting & ParticipantsA sample of 14,071 patients with sustained estimated glomerular filtration rates < 15mL/min/1.73m2 treated in the US Veterans Affairs health care system who died during 2000 to 2011. Before death, 12,756 of these patients had been treated with dialysis, 503 had been discussing and/or preparing for dialysis therapy, and for 812, there had been a decision not to pursue dialysis therapy.OutcomesHospitalization and receipt of an intensive procedure during the final month of life, in-hospital death, and palliative care consultation and hospice enrollment before death.ResultsCompared with decedents treated with dialysis, those for whom a decision not to pursue dialysis therapy had been made were less often hospitalized (57.3% vs 76.8%; OR, 0.40 [95% CI, 0.34-0.46]), less often the recipient of an intensive procedure (3.5% vs 24.6%; OR, 0.15 [95% CI, 0.10-0.22]), more often the recipient of a palliative care consultation (52.6% vs 21.6%; OR, 4.19 [95% CI, 3.58-4.90]), more often used hospice services (38.7% vs 18.2%; OR, 3.32 [95% CI, 2.83-3.89]), and died less frequently in a hospital (41.4% vs 57.3%; OR, 0.78 [95% CI, 0.74-0.82]). Hospitalization (55.5%; OR, 0.39 [95% CI, 0.32-0.46]), receipt of an intensive procedure (13.7%; OR, 0.60 [95% CI, 0.46-0.77]), and in-hospital death (39.0%; OR, 0.47 [95% CI, 0.39-0.56]) were also less common among decedents who had been discussing and/or preparing for dialysis therapy, but their use of palliative care and hospice services was similar.LimitationsFindings may not be generalizable to groups not well represented in the Veterans Affairs health care system.ConclusionsAmong decedents, patients not treated with dialysis before death received less intensive patterns of end-of-life care than those treated with dialysis. Decedents for whom there had been a decision not to pursue dialysis therapy before death were more likely to receive palliative care and hospice.Published by Elsevier Inc.

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