Association Between Hospice Length of Stay, Health Care Utilization, and Medicare Costs at the End of Life Among Patients Who Received Maintenance Hemodialysis | Nephrology | JAMA Internal Medicine | JAMA Network
[Skip to Navigation]
Sign In
Figure 1.  CONSORT Diagram
CONSORT Diagram

CONSORT indicates Consolidated Standards of Reporting Trials; ESRD, end-stage renal disease.

Figure 2.  Patients Grouped According to Whether They Were Enrolled in Hospice at the Time of Death and the Number of Days in Hospice Before Death
Patients Grouped According to Whether They Were Enrolled in Hospice at the Time of Death and the Number of Days in Hospice Before Death

A, Models were adjusted for age, sex, race, Hispanic ethnicity, dual Medicare-Medicaid eligibility, comorbid conditions (diabetes, cirrhosis, dementia, cancer, coronary artery disease, stroke, peripheral artery disease, congestive heart failure, and emphysema), Quan comorbidity score, regional health care intensity, and hemodialysis discontinuation status. Adjusted proportions differed significantly for each hospice length of stay compared with the referent group of patients not referred to hospice for all outcomes (P < .001). ICU indicates intensive care unit. B, Models were adjusted for the same variables as in A. Shown are adjusted mean costs to the Medicare program under Medicare Parts A and B in the last week of life adjusted to the 2014 consumer price index. Costs differed significantly for each hospice length of stay compared with the referent group of patients not referred to hospice (P < .001), with the exception that there was no significant difference in costs between patients who spent 3 days or fewer in hospice and those not referred to hospice (P = .08).

Table.  Characteristics of Medicare Beneficiaries Who Had Received Maintenance Hemodialysis Who Died During 2000 to 2014a
Characteristics of Medicare Beneficiaries Who Had Received Maintenance Hemodialysis Who Died During 2000 to 2014a
1.
Medicare Payment Advisory Commission (MedPAC). Report to the Congress: Medicare payment policy. http://medpac.gov/docs/default-source/reports/march-2016-report-to-the-congress-medicare-payment-policy.pdf?sfvrsn=0. Accessed July 6, 2017.
2.
Wright  AA, Keating  NL, Balboni  TA, Matulonis  UA, Block  SD, Prigerson  HG.  Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers’ mental health.  J Clin Oncol. 2010;28(29):4457-4464.PubMedGoogle ScholarCrossref
3.
Kleinpell  R, Vasilevskis  EE, Fogg  L, Ely  EW.  Exploring the association of hospice care on patient experience and outcomes of care  [published online August 16, 2016].  BMJ Support Palliat Care. doi:10.1136/bmjspcare-2015-001001Google Scholar
4.
Currow  DC, Abernethy  AP, Bausewein  C, Johnson  M, Harding  R, Higginson  I.  Measuring the net benefits of hospice and palliative care: a composite measure for multiple audiences—palliative net benefit.  J Palliat Med. 2011;14(3):264-265.PubMedGoogle ScholarCrossref
5.
Teno  JM, Gozalo  PL, Bynum  JP,  et al.  Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009.  JAMA. 2013;309(5):470-477.PubMedGoogle ScholarCrossref
6.
Schockett  ER, Teno  JM, Miller  SC, Stuart  B.  Late referral to hospice and bereaved family member perception of quality of end-of-life care.  J Pain Symptom Manage. 2005;30(5):400-407.PubMedGoogle ScholarCrossref
7.
Rickerson  E, Harrold  J, Kapo  J, Carroll  JT, Casarett  D.  Timing of hospice referral and families’ perceptions of services: are earlier hospice referrals better?  J Am Geriatr Soc. 2005;53(5):819-823.PubMedGoogle ScholarCrossref
8.
Casarett  DJ.  Rethinking hospice eligibility criteria.  JAMA. 2011;305(10):1031-1032.PubMedGoogle ScholarCrossref
9.
Cohen  LM, McCue  JD, Germain  M, Kjellstrand  CM.  Dialysis discontinuation: a “good” death?  Arch Intern Med. 1995;155(1):42-47.PubMedGoogle ScholarCrossref
10.
O’Connor  NR, Dougherty  M, Harris  PS, Casarett  DJ.  Survival after dialysis discontinuation and hospice enrollment for ESRD.  Clin J Am Soc Nephrol. 2013;8(12):2117-2122.PubMedGoogle ScholarCrossref
11.
Wong  SP, Kreuter  W, O’Hare  AM.  Treatment intensity at the end of life in older adults receiving long-term dialysis.  Arch Intern Med. 2012;172(8):661-663.PubMedGoogle ScholarCrossref
12.
Kelley  AS, Deb  P, Du  Q, Aldridge Carlson  MD, Morrison  RS.  Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay.  Health Aff (Millwood). 2013;32(3):552-561.PubMedGoogle ScholarCrossref
13.
Cassel  CK, Field  MJ.  Approaching Death: Improving Care at the End of Life. Washington, DC: National Academies Press; 1997.
14.
Barnato  AE, Herndon  MB, Anthony  DL,  et al.  Are regional variations in end-of-life care intensity explained by patient preferences?: a study of the US Medicare population.  Med Care. 2007;45(5):386-393.PubMedGoogle ScholarCrossref
15.
Cohen  LM, Ruthazer  R, Moss  AH, Germain  MJ.  Predicting six-month mortality for patients who are on maintenance hemodialysis.  Clin J Am Soc Nephrol. 2010;5(1):72-79.PubMedGoogle ScholarCrossref
16.
Kurella Tamura  M, Covinsky  KE, Chertow  GM, Yaffe  K, Landefeld  CS, McCulloch  CE.  Functional status of elderly adults before and after initiation of dialysis.  N Engl J Med. 2009;361(16):1539-1547.PubMedGoogle ScholarCrossref
17.
Nordio  M, Limido  A, Maggiore  U, Nichelatti  M, Postorino  M, Quintaliani  G; Italian Dialysis and Transplantation Registry.  Survival in patients treated by long-term dialysis compared with the general population.  Am J Kidney Dis. 2012;59(6):819-828.PubMedGoogle ScholarCrossref
18.
O’Hare  AM, Bertenthal  D, Covinsky  KE,  et al.  Mortality risk stratification in chronic kidney disease: one size for all ages?  J Am Soc Nephrol. 2006;17(3):846-853.PubMedGoogle ScholarCrossref
19.
Schell  JO, Da Silva-Gane  M, Germain  MJ.  Recent insights into life expectancy with and without dialysis.  Curr Opin Nephrol Hypertens. 2013;22(2):185-192.PubMedGoogle ScholarCrossref
20.
Winkelmayer  WC, Glynn  RJ, Mittleman  MA, Levin  R, Pliskin  JS, Avorn  J.  Comparing mortality of elderly patients on hemodialysis versus peritoneal dialysis: a propensity score approach.  J Am Soc Nephrol. 2002;13(9):2353-2362.PubMedGoogle ScholarCrossref
21.
Davison  SN.  Pain in hemodialysis patients: prevalence, cause, severity, and management.  Am J Kidney Dis. 2003;42(6):1239-1247.PubMedGoogle ScholarCrossref
22.
Merkus  MP, Jager  KJ, Dekker  FW, de Haan  RJ, Boeschoten  EW, Krediet  RT.  Physical symptoms and quality of life in patients on chronic dialysis: results of the Netherlands Cooperative Study on Adequacy of Dialysis (NECOSAD).  Nephrol Dial Transplant. 1999;14(5):1163-1170.PubMedGoogle ScholarCrossref
23.
Parfrey  P, Vavasour  H, Bullock  M, Henry  S, Harnett  J, Gault  M.  Symptoms in end-stage renal disease: dialysis v transplantation.  Transplant Proc. 1987;19(4):3407-3409. PubMedGoogle Scholar
24.
Parfrey  PS, Vavasour  HM, Henry  S, Bullock  M, Gault  MH.  Clinical features and severity of nonspecific symptoms in dialysis patients.  Nephron. 1988;50(2):121-128.PubMedGoogle ScholarCrossref
25.
Devins  GM, Armstrong  SJ, Mandin  H,  et al.  Recurrent pain, illness intrusiveness, and quality of life in end-stage renal disease.  Pain. 1990;42(3):279-285.PubMedGoogle ScholarCrossref
26.
Curtin  RB, Bultman  DC, Thomas-Hawkins  C, Walters  BA, Schatell  D.  Hemodialysis patients’ symptom experiences: effects on physical and mental functioning.  Nephrol Nurs J. 2002;29(6):562-574.PubMedGoogle Scholar
27.
Watnick  S, Kirwin  P, Mahnensmith  R, Concato  J.  The prevalence and treatment of depression among patients starting dialysis.  Am J Kidney Dis. 2003;41(1):105-110.PubMedGoogle ScholarCrossref
28.
Yong  DS, Kwok  AO, Wong  DM, Suen  MH, Chen  WT, Tse  DM.  Symptom burden and quality of life in end-stage renal disease: a study of 179 patients on dialysis and palliative care.  Palliat Med. 2009;23(2):111-119.PubMedGoogle ScholarCrossref
29.
Murtagh  FE, Addington-Hall  J, Higginson  IJ.  The prevalence of symptoms in end-stage renal disease: a systematic review.  Adv Chronic Kidney Dis. 2007;14(1):82-99.PubMedGoogle ScholarCrossref
30.
Wong  SP, Kreuter  W, O’Hare  AM.  Healthcare intensity at initiation of chronic dialysis among older adults.  J Am Soc Nephrol. 2014;25(1):143-149.PubMedGoogle ScholarCrossref
31.
Wong  SP, Kreuter  W, Curtis  JR, Hall  YN, O’Hare  AM.  Trends in in-hospital cardiopulmonary resuscitation and survival in adults receiving maintenance dialysis.  JAMA Intern Med. 2015;175(6):1028-1035.PubMedGoogle ScholarCrossref
32.
O’Hare  AM, Rodriguez  RA, Hailpern  SM, Larson  EB, Kurella Tamura  M.  Regional variation in health care intensity and treatment practices for end-stage renal disease in older adults.  JAMA. 2010;304(2):180-186.PubMedGoogle ScholarCrossref
33.
Wachterman  MW, Pilver  C, Smith  D, Ersek  M, Lipsitz  SR, Keating  NL.  Quality of end-of-life care provided to patients with different serious illnesses.  JAMA Intern Med. 2016;176(8):1095-1102.PubMedGoogle ScholarCrossref
34.
Quan  H, Sundararajan  V, Halfon  P,  et al.  Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.  Med Care. 2005;43(11):1130-1139.PubMedGoogle ScholarCrossref
35.
Fisher  ES, Wennberg  DE, Stukel  TA, Gottlieb  DJ, Lucas  FL, Pinder  EL.  The implications of regional variations in Medicare spending, part 2: health outcomes and satisfaction with care.  Ann Intern Med. 2003;138(4):288-298.PubMedGoogle ScholarCrossref
36.
Barnato  AE, Farrell  MH, Chang  CC, Lave  JR, Roberts  MS, Angus  DC.  Development and validation of hospital “end-of-life” treatment intensity measures.  Med Care. 2009;47(10):1098-1105.PubMedGoogle ScholarCrossref
37.
Murray  AM, Arko  C, Chen  SC, Gilbertson  DT, Moss  AH.  Use of hospice in the United States dialysis population.  Clin J Am Soc Nephrol. 2006;1(6):1248-1255.PubMedGoogle ScholarCrossref
38.
Hogan  C; Medical Payment Advisory Commission (MedPAC). Spending in the last year of life and the impact of hospice on Medicare outlays. http://www.medpac.gov/docs/default-source/contractor-reports/spending-in-the-last-year-of-life-and-the-impact-of-hospice-on-medicare-outlays-updated-august-2015-.pdf?sfvrsn=0. Updated August 2015. Accessed July 6, 2017.
39.
Zuckerman  RB, Stearns  SC, Sheingold  SH.  Hospice use, hospitalization, and Medicare spending at the end of life.  J Gerontol B Psychol Sci Soc Sci. 2016;71(3):569-580.PubMedGoogle ScholarCrossref
40.
Taylor  DH  Jr, Ostermann  J, Van Houtven  CH, Tulsky  JA, Steinhauser  K.  What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program?  Soc Sci Med. 2007;65(7):1466-1478.PubMedGoogle ScholarCrossref
41.
Gozalo  P, Plotzke  M, Mor  V, Miller  SC, Teno  JM.  Changes in Medicare costs with the growth of hospice care in nursing homes.  N Engl J Med. 2015;372(19):1823-1831.PubMedGoogle ScholarCrossref
42.
Obermeyer  Z, Makar  M, Abujaber  S, Dominici  F, Block  S, Cutler  DM.  Association between the Medicare hospice benefit and health care utilization and costs for patients with poor-prognosis cancer.  JAMA. 2014;312(18):1888-1896.PubMedGoogle ScholarCrossref
43.
Wang  S, Hsu  SH, Huang  S, Soulos  PR, Gross  CP.  Longer periods of hospice service associated with lower end-of-life spending in regions with high expenditures.  Health Aff (Millwood). 2017;36(2):328-336.PubMedGoogle ScholarCrossref
44.
O’Hare  AM, Szarka  J, McFarland  LV,  et al.  Provider perspectives on advance care planning for patients with kidney disease: whose job is it anyway?  Clin J Am Soc Nephrol. 2016;11(5):855-866.PubMedGoogle ScholarCrossref
45.
Wong  SP, Vig  EK, Taylor  JS,  et al.  Timing of initiation of maintenance dialysis: a qualitative analysis of the electronic medical records of a national cohort of patients from the Department of Veterans Affairs.  JAMA Intern Med. 2016;176(2):228-235.PubMedGoogle ScholarCrossref
46.
Russ  AJ, Shim  JK, Kaufman  SR.  The value of “life at any cost”: talk about stopping kidney dialysis.  Soc Sci Med. 2007;64(11):2236-2247.PubMedGoogle ScholarCrossref
47.
Wachterman  MW, Marcantonio  ER, Davis  RB,  et al.  Relationship between the prognostic expectations of seriously ill patients undergoing hemodialysis and their nephrologists.  JAMA Intern Med. 2013;173(13):1206-1214.PubMedGoogle ScholarCrossref
48.
Lunney  JR, Lynn  J, Foley  DJ, Lipson  S, Guralnik  JM.  Patterns of functional decline at the end of life.  JAMA. 2003;289(18):2387-2392.PubMedGoogle ScholarCrossref
49.
Harris  P, Wong  E, Farrington  S,  et al.  Patterns of functional decline in hospice: what can individuals and their families expect?  J Am Geriatr Soc. 2013;61(3):413-417.PubMedGoogle ScholarCrossref
50.
Teno  JM, Weitzen  S, Fennell  ML, Mor  V.  Dying trajectory in the last year of life: does cancer trajectory fit other diseases?  J Palliat Med. 2001;4(4):457-464.PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Original Investigation
    June 2018

    Association Between Hospice Length of Stay, Health Care Utilization, and Medicare Costs at the End of Life Among Patients Who Received Maintenance Hemodialysis

    Author Affiliations
    • 1Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
    • 2Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
    • 3Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
    • 4Division of Nephrology, Kidney Research Institute, Department of Medicine, University of Washington, Seattle
    • 5Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
    • 6Division of Nephrology, Department of Medicine, Stanford University, Palo Alto, California
    • 7Geriatric Research and Education Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
    • 8Hospital and Specialty Medical Service, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
    JAMA Intern Med. 2018;178(6):792-799. doi:10.1001/jamainternmed.2018.0256
    Key Points

    Question  What is the association between hospice length of stay and end-of-life health care utilization and costs among hemodialysis patients?

    Findings  In this cross-sectional study of 770 191 Medicare beneficiaries, 20% of maintenance hemodialysis patients enrolled in hospice; of these, 41.5% received 3 days or fewer of hospice. While these patients with very short hospice stays were less likely than those without hospice stays to die in the hospital and receive intensive procedures, rates of hospitalization, intensive care unit admission, and Medicare costs were comparable to or higher than for patients who did not receive hospice.

    Meaning  Late hospice referral may limit the effect of hospice on end-of-life health care utilization and costs among dialysis patients.

    Abstract

    Importance  Patients with end-stage renal disease are less likely to use hospice services than other patients with advanced chronic illness. Little is known about the timing of hospice referral in this population and its association with health care utilization and costs.

    Objective  To examine the association between hospice length of stay and health care utilization and costs at the end of life among Medicare beneficiaries who had received maintenance hemodialysis.

    Design, Setting, and Participants  This cross-sectional observational study was conducted via the United States Renal Data System registry. Participants were all 770 191 hemodialysis patients in the registry who were enrolled in fee-for-service Medicare and died between January 1, 2000, and December 31, 2014. The dates of analysis were April 2016 to December 2017.

    Main Outcomes and Measures  Hospital admission, intensive care unit (ICU) admission, and receipt of an intensive procedure during the last month of life; death in the hospital; and costs to the Medicare program in the last week of life.

    Results  Among 770 191 patients, the mean (SD) age was 74.8 (11.0) years, and 53.7% were male. Twenty percent of cohort members were receiving hospice services when they died. Of these, 41.5% received hospice for 3 days or fewer. In adjusted analyses, compared with patients who did not receive hospice, those enrolled in hospice for 3 days or fewer were less likely to die in the hospital (13.5% vs 55.1%; P < .001) or to undergo an intensive procedure in the last month of life (17.7% vs 31.6%; P < .001) but had higher rates of hospitalization (83.6% vs 74.4%; P < .001) and ICU admission (54.0% vs 51.0%; P < .001) and similar Medicare costs in the last week of life ($10 756 vs $10 871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with progressively lower rates of utilization and costs, especially for those referred more than 15 days before death (35.1% hospitalized and 16.7% admitted to an ICU in the last month of life; the mean Medicare costs in the last week of life were $3221).

    Conclusions and Relevance  Overall, 41.5% of hospice enrollees who had been treated with hemodialysis for their end-stage renal disease entered hospice within 3 days of death. Although less likely to die in the hospital and to receive an intensive procedure, these patients were more likely than those not enrolled in hospice to be hospitalized and admitted to the ICU, and they had similar Medicare costs. Without addressing barriers to more timely referral, greater use of hospice may not translate into meaningful changes in patterns of health care utilization, costs, and quality of care at the end of life in this population.

    Introduction

    Use of hospice has increased markedly in the overall Medicare population in recent years,1 with the percentage of Medicare beneficiaries who received hospice before death more than doubling from 23% in 2000 to 48% in 2014. While hospice offers clear benefits to patients approaching the end of life and to their families,2-4 the Medicare hospice benefit, established in 1986, requires hospice enrollees to discontinue disease-modifying treatment for the condition listed as their hospice diagnosis. This may explain in part why, despite increases over time in the percentage of Medicare beneficiaries who receive hospice services at the end of life, hospice referral continues to occur very late in the course of illness for a substantial portion of those referred. From 2000 to 2009, the proportion of Medicare hospice beneficiaries not referred until the last 3 days of life increased from 22% to 28%.5 This is concerning because shorter hospice stays have been associated with lower-quality end-of-life care, including inadequate pain control and unmet emotional needs.6,7

    Nowhere is the tension between timely receipt of hospice care and continuation of treatments that may both extend life and palliate symptoms more pronounced than for those patients receiving maintenance hemodialysis. In instances where end-stage renal disease (ESRD) is viewed as the life-limiting condition, patients cannot receive concurrent Medicare coverage for hospice and hemodialysis. This Medicare payment policy, which has the effect of forcing patients to choose between receiving hospice services and continuing treatments considered to be “curative,”8 takes on a special significance for this population because most live for less than 1 week after stopping hemodialysis.9 Therefore, it is not surprising that patients who have been treated with maintenance hemodialysis are much less likely to be referred to hospice than other chronically ill populations.10,11 However, less is known about the timing of hospice referral in this population.

    In the overall Medicare population, even very short hospice stays appear to be associated with lower rates of hospital admission, intensive care unit (ICU) admission, and in-hospital death,12 which may reflect higher-quality end-of-life care because evidence suggests that most Americans would prefer not to die in the hospital.13,14 Patients with ESRD may stand to gain much from hospice care: many have limited life expectancy15-20 and a high symptom burden21-29 and receive extremely intensive care at the end of life,11,30-32 which may be inconsistent with their preferences.33 Whether the association between the timing of hospice referral and health care utilization and costs for these patients is similar to that for the overall Medicare population—for whom even very short stays in hospice are associated with lower utilization and costs compared with those not referred to hospice—is not known. To address this question, we designed a study to examine hospice length of stay and its association with health care utilization and costs at the end of life among Medicare beneficiaries who had been treated with maintenance hemodialysis.

    Methods
    Data Source and Study Cohort

    In this cross-sectional observational study, we identified all patients in the United States Renal Data System (USRDS) registry who died between January 1, 2000, and December 31, 2014, and were enrolled in Parts A and B of fee-for-service Medicare during their final year of life (n = 857 589). The dates of analysis were April 2016 to December 2017. Analyses were conducted among the subset of 770 191 of these patients 18 years or older for whom the most recent treatment modality before death was hemodialysis (vs kidney transplant or peritoneal dialysis) (Figure 1). The institutional review board at the University of Washington approved the study protocol.

    Primary Variable of Interest

    We grouped patients according to whether they were enrolled in hospice at the time of death, and, if so, by the duration of enrollment. The groups were as follows: (1) not enrolled in hospice at death, (2) enrolled within 3 days of death, (3) enrolled 4 to 7 days before death, (4) enrolled 8 to 14 days before death, and (5) enrolled for 15 days or more before death.

    Covariates

    We used USRDS standard analysis files to ascertain each patient’s age at the time of death (categorized as 18-44, 45-64, 65-74, 75-84, and ≥85 years), sex, race, and Hispanic ethnicity. We used the USRDS payer history file to identify patients with dual Medicare-Medicaid eligibility in the year before death. Comorbid conditions (diabetes, cirrhosis, dementia, cancer, coronary artery disease, stroke, peripheral arterial disease, congestive heart failure, and emphysema) and Quan comorbidity score34 were ascertained using International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes in the Medicare institutional and physician supplier claims for both inpatient and outpatient care at a time point 1 year before death based on claims during the preceding year (ie, 12-24 months before death). Regional health care intensity was based on the average inpatient health care costs during the last 6 months of life in each patient’s hospital referral region of residence closest to the time of death, as reported in the Dartmouth Atlas of Health Care35 for 2014, and categorized by quintile.

    We determined whether patients had a primary hospice diagnosis of renal failure based on the ICD-9 code recorded in the Medicare hospice file (the eTable in the Supplement lists specific ICD-9 codes for different primary hospice diagnoses). Time from first hemodialysis to death was calculated by subtracting each patient’s date of first ESRD service from their date of death recorded in the USRDS patients file. Whether there was a decision to discontinue hemodialysis before death was ascertained from the Centers for Medicare & Medicaid Services (CMS) ESRD death notification form (CMS-2746).

    Outcomes

    We examined the following measures of health care utilization during the last month of life: hospital admission, ICU admission, death in the hospital, and receipt of 1 or more inpatient intensive procedures. In addition, we assessed health care costs to the Medicare program under Medicare Parts A and B (hereafter referred to as “costs”) in the last week of life standardized to the 2014 consumer price index: these included costs for hemodialysis, hospice (paid to hospices at a per diem rate), acute inpatient care, and outpatient health care provider visits. Intensive care unit utilization was ascertained using intensive and coronary care unit revenue center codes in Medicare institutional claims (020x and 021x). Inpatient intensive procedures were identified using ICD-9 procedure codes in inpatient Medicare institutional claims and included intubation and mechanical ventilation (codes 96.04, 96.05, and 96.7x), tracheostomy (codes 31.1, 31.21, and 31.29), gastrostomy tube insertion (codes 43.2, 43.11, 43.19, 43.2, and 44.32), enteral or parenteral nutrition (codes 96.6 and 99.15), and cardiopulmonary resuscitation (codes 99.60 and 99.63).11,36

    Statistical Analysis

    We described patient characteristics by hospice length of stay using the mean (SD) or median (interquartile range [IQR]) values for continuous variables and percentages for categorical variables. We used generalized linear models to calculate marginal prevalence estimates and the mean Medicare costs by hospice length of stay after adjustment for potential confounders. Models were adjusted for age, sex, race, Hispanic ethnicity, dual Medicare-Medicaid eligibility, comorbid conditions (diabetes, cirrhosis, dementia, cancer, coronary artery disease, stroke, peripheral artery disease, congestive heart failure, and emphysema), Quan comorbidity score,34 regional health care intensity, and whether there was a decision to discontinue hemodialysis before death. All analyses were conducted using Stata/SE (version 13.1; StataCorp LP), and 2-sided P values are presented.

    Results

    Among 770 191 Medicare beneficiaries receiving maintenance hemodialysis who died between 2000 and 2014, a total of 154 186 (20.0%) were receiving hospice services at the time of death. Among these, the median length of stay in hospice was 5 days (IQR, 2-12 days). Overall, 41.5% of these patients enrolled in hospice within 3 days of death, 22.5% within 4 to 7 days, 14.3% within 8 to 14 days, and 21.7% within 15 days or more before death (Table). While the percentage of Medicare beneficiaries treated with hemodialysis who used hospice more than doubled from 11.0% in 2000 to 26.7% in 2014, the percentage of these patients spending 3 days or fewer in hospice was stable over this period (43.6% in 2000 to 41.7% in 2014).

    As summarized in the Table, patients enrolled in hospice at the time of death were on average older than those not enrolled, but there were no large age differences among patients with differing hospice lengths of stay. Patients of black race were less likely than patients of white race to die in hospice but were more likely to spend longer time in hospice. Overall, comorbid disease burden was similar across groups, with the exception that a higher proportion of those who died in hospice had dementia or cancer compared with those who did not die in hospice. Dementia and cancer were also more prevalent among patients who spent a longer period in hospice. Only 13.9% of those who did not die in hospice discontinued hemodialysis before death compared with 66.3% of those who died in hospice. Among hospice users, 55.9% had a primary hospice diagnosis of renal failure (diagnoses for the remaining patients are listed in the eTable in the Supplement). Patients enrolled in hospice for longer periods were less likely to have discontinued hemodialysis and to have a primary hospice diagnosis of renal failure.

    Figure 2 shows adjusted patterns of end-of-life health care utilization and Medicare costs by length of time in hospice (unadjusted findings are shown in the eFigure in the Supplement). The adjusted proportion of patients admitted to the hospital in the last month of life was lowest for those in hospice for 15 days or more (35.1%) and was highest for those in hospice for 3 days or fewer (83.6%) (ie, higher than for those who did not enroll in hospice [74.4%]). Intensive care unit admission in the last month of life followed a similar pattern, with 16.7% of those in hospice for 15 days or more admitted to the ICU compared with 54.0% of those in hospice for 3 days or fewer and 51.0% of those who did not enroll in hospice. The proportion of patients who received an inpatient intensive procedure was highest for those who did not enroll in hospice (31.6%) and was higher among those who spent a shorter time in hospice (ranging from 17.7% for those in hospice for ≤3 days to 3.0% for those in hospice for ≥15 days). While more than half of the patients not referred to hospice died in the hospital (55.1%), this was true for only 13.5% of those who spent 3 days or fewer in hospice and for less than 5% of patients who spent longer periods in hospice. Adjusted mean Medicare costs were similar for patients who spent 3 days or fewer in hospice and for those not referred to hospice ($10 756 vs $10 871; P = .08). Medicare costs and rates of all utilization measures decreased with increasing lengths of stay beyond 3 days.

    Discussion

    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. However, there was little change during this time in hospice length of stay for members of this population, with 41.5% of those dying in hospice enrolled for 3 days or less. For these patients enrolled in hospice very close to the time of death, rates of hospital admission and ICU admission were higher than, and Medicare costs similar to, those for patients not enrolled in hospice. Longer lengths of stay in hospice beyond 3 days were associated with progressively lower rates of health care utilization and costs, especially for those referred more than 15 days before death.

    To our knowledge, this study (which uses data from 2000 to 2014) is the first to look at rates of hospice utilization among Medicare beneficiaries with ESRD since Murray et al37 reported a rate of 14% using data from 2000 to 2003. Our study demonstrates that from 2000 to 2014 hospice utilization among Medicare beneficiaries who had been treated with maintenance hemodialysis more than doubled from 11.0% to 26.7% but still lags substantially behind that for the broader Medicare population. Over a similar period (2002-2012), rates of hospice utilization among the overall population of older Medicare beneficiaries increased from 26% to 47%.38 Most strikingly, we observed comparatively late hospice referrals among Medicare beneficiaries who had been treated with maintenance hemodialysis that persisted throughout the period under study: 41.5% of hospice users in our study did not enroll until the last 3 days of life compared with the 25% reported for older Medicare hospice beneficiaries.5 Almost two-thirds (64.0%) of hospice users in our study received 1 week or less of hospice care compared with 39%, 36%, and 34% reported for Medicare hospice beneficiaries with heart failure, colorectal cancer, and dementia, respectively.39 This is concerning because short hospice stays have been associated with inadequate pain control and unmet emotional needs.6,7

    To our knowledge, this study is the first to examine the association between hospice length of stay and patterns of health care utilization and costs near the end of life in the ESRD population. While prior studies among patients with ESRD have described strong associations between hospice referral and health care utilization11,37 and Medicare costs,37 we found that (consistent with prior literature in other patient populations12,39-43) these associations are heavily contingent on the time spent in hospice and the specific measures examined. We found that longer lengths of stay in hospice were generally associated with lower health care utilization and costs. Being in hospice for more than 2 weeks was associated with markedly lower hospital and ICU admission rates, a total of just 4 to 7 days of hospice was associated with much lower Medicare costs and rates of intensive procedures, and even very short stays in hospice were associated with markedly lower rates of death in the hospital. However, for a number of measures, such as hospital and ICU admission in the last month of life and Medicare costs in the last week of life, those who enrolled in hospice within 3 days of death had similar costs and more intensive patterns of health care utilization than those not referred to 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.44,45 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.

    While having the option to discontinue hemodialysis and exercise some control over the timing of death has been described by some as “a blessing,”9 others may be forced to discontinue hemodialysis before they are ready so as to receive hospice services. To better understand the implications of late referral to hospice for patients receiving maintenance hemodialysis, more work is needed to gain a deeper understanding of the end-of-life experiences of patients treated with maintenance hemodialysis and their family members and friends. For those in whom more timely receipt of hospice care would be beneficial, efforts are needed to understand barriers to and facilitators of hospice referral and identify opportunities for more timely transitions to hospice.

    While a change in Medicare payment policy to allow for concurrent receipt of hemodialysis and hospice services for these patients would be needed to allow for greater flexibility in the timing of hospice referral in the ESRD population, this alone may not be sufficient to improve access to timely hospice care for members of this population. Interventions targeted at other potential barriers to timely hospice referral may also be needed. Compared with most other broadly defined populations with advanced chronic illness, a distinguishing feature of patients treated with maintenance hemodialysis is that they are already receiving 1 form of chronic life support. In so doing, they have already been drawn into a highly medicalized “life at any cost”46 disease-oriented model of care in which patients may have unrealistic prognostic expectations.47 Furthermore, renal failure may be seen by both patients and clinicians as a problem that can be “fixed” with hemodialysis, with hospice and palliative care viewed as treatments of last resort. Illness trajectories may also be less predictable for patients with advanced organ failure than for those with cancer, perhaps contributing to shorter hospice stays.48-50 Nevertheless, hospice referral among members of our cohort who had been receiving hemodialysis appears to occur much later in the course of illness than for those with other forms of organ failure (eg, heart failure and chronic lung disease) characterized by a similar degree of prognostic uncertainty.39

    Earlier and more frequent integration of palliative care services into the care of patients receiving hemodialysis is an intervention that could potentially target a number of these barriers. While Medicare payment policy serves as a barrier to concurrent use of hemodialysis and hospice services for those with a life-limiting diagnosis of renal failure, rates of palliative care in this population are also low,33 despite the absence of such policy barriers to concurrent receipt of palliative care services and hemodialysis. Earlier integration of palliative care could likely address the substantial and often unrecognized symptom, functional, and caregiving burden faced by many hemodialysis patients and their family members and friends, especially for those who are older or frail. 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.

    Limitations

    Our study has several limitations. Although the USRDS registry includes all US patients receiving maintenance hemodialysis, the registry does not include patients with ESRD who are not treated with hemodialysis. Therefore, we cannot report on hospice utilization among this important subset of the population with ESRD. Moreover, the generalizability of our findings to patients enrolled in Medicare Advantage, patients with private insurance, and those covered by federal programs, such as the Department of Veterans Affairs, requires further study. In addition, the USRDS does not collect information about patient and family treatment preferences; therefore, we could not assess whether care was concordant with such preferences. Another limitation is that the CMS ESRD death notification form (CMS-2746) provides limited information on the clinical context in which hemodialysis discontinuation occurred. Last, and perhaps most important, although our study showed strong associations between hospice length of stay and health care utilization and costs, it is an observational study, and conclusions cannot be drawn about whether lengthening hospice stays would lead to decreased utilization and costs.

    Conclusions

    Hospice referral among patients treated with maintenance hemodialysis occurs very late in the course of illness as an apparent add-on to intensive patterns of care. Without measures to make hospice accessible earlier in the illness trajectory or efforts to better integrate palliative care services into the care of patients receiving maintenance hemodialysis, greater use of hospice is unlikely to translate into meaningful changes in patterns of health care utilization, costs, and quality of end-of-life care in the ESRD population.

    Back to top
    Article Information

    Accepted for Publication: January 13, 2018.

    Corresponding Author: Melissa W. Wachterman, MD, MSc, MPH, Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, 150 S Huntington Ave, Building 9, Boston, MA 02130 (mwachterman@partners.org).

    Published Online: April 30, 2018. doi:10.1001/jamainternmed.2018.0256

    Author Contributions: Dr O’Hare had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Study concept and design: Wachterman, Keating, O’Hare.

    Acquisition, analysis, or interpretation of data: Wachterman, Hailpern, Kurella Tamura, O’Hare.

    Drafting of the manuscript: Wachterman, Hailpern.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Wachterman, Hailpern, O’Hare.

    Obtained funding: Wachterman, Kurella Tamura, O’Hare.

    Administrative, technical, or material support: Kurella Tamura, O’Hare.

    Study supervision: O’Hare.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This work was supported by grant U01DK102150 from the National Institute of Diabetes and Digestive and Kidney Diseases. Dr Wachterman also received support from the National Palliative Care Research Center Junior Faculty Career Development Award and by grant 1K23AG049088 from the National Institute on Aging.

    Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The interpretation of these data is the sole responsibility of the authors and does not reflect the opinion of the Department of Veterans Affairs or the United States Renal Data System.

    Additional Contributions: Gabrielle Kate Alicante, BS, Harvard Medical School, assisted with the preparation of the manuscript, including formatting tables and figures, as part of her duties as a paid research assistant.

    References
    1.
    Medicare Payment Advisory Commission (MedPAC). Report to the Congress: Medicare payment policy. http://medpac.gov/docs/default-source/reports/march-2016-report-to-the-congress-medicare-payment-policy.pdf?sfvrsn=0. Accessed July 6, 2017.
    2.
    Wright  AA, Keating  NL, Balboni  TA, Matulonis  UA, Block  SD, Prigerson  HG.  Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers’ mental health.  J Clin Oncol. 2010;28(29):4457-4464.PubMedGoogle ScholarCrossref
    3.
    Kleinpell  R, Vasilevskis  EE, Fogg  L, Ely  EW.  Exploring the association of hospice care on patient experience and outcomes of care  [published online August 16, 2016].  BMJ Support Palliat Care. doi:10.1136/bmjspcare-2015-001001Google Scholar
    4.
    Currow  DC, Abernethy  AP, Bausewein  C, Johnson  M, Harding  R, Higginson  I.  Measuring the net benefits of hospice and palliative care: a composite measure for multiple audiences—palliative net benefit.  J Palliat Med. 2011;14(3):264-265.PubMedGoogle ScholarCrossref
    5.
    Teno  JM, Gozalo  PL, Bynum  JP,  et al.  Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009.  JAMA. 2013;309(5):470-477.PubMedGoogle ScholarCrossref
    6.
    Schockett  ER, Teno  JM, Miller  SC, Stuart  B.  Late referral to hospice and bereaved family member perception of quality of end-of-life care.  J Pain Symptom Manage. 2005;30(5):400-407.PubMedGoogle ScholarCrossref
    7.
    Rickerson  E, Harrold  J, Kapo  J, Carroll  JT, Casarett  D.  Timing of hospice referral and families’ perceptions of services: are earlier hospice referrals better?  J Am Geriatr Soc. 2005;53(5):819-823.PubMedGoogle ScholarCrossref
    8.
    Casarett  DJ.  Rethinking hospice eligibility criteria.  JAMA. 2011;305(10):1031-1032.PubMedGoogle ScholarCrossref
    9.
    Cohen  LM, McCue  JD, Germain  M, Kjellstrand  CM.  Dialysis discontinuation: a “good” death?  Arch Intern Med. 1995;155(1):42-47.PubMedGoogle ScholarCrossref
    10.
    O’Connor  NR, Dougherty  M, Harris  PS, Casarett  DJ.  Survival after dialysis discontinuation and hospice enrollment for ESRD.  Clin J Am Soc Nephrol. 2013;8(12):2117-2122.PubMedGoogle ScholarCrossref
    11.
    Wong  SP, Kreuter  W, O’Hare  AM.  Treatment intensity at the end of life in older adults receiving long-term dialysis.  Arch Intern Med. 2012;172(8):661-663.PubMedGoogle ScholarCrossref
    12.
    Kelley  AS, Deb  P, Du  Q, Aldridge Carlson  MD, Morrison  RS.  Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay.  Health Aff (Millwood). 2013;32(3):552-561.PubMedGoogle ScholarCrossref
    13.
    Cassel  CK, Field  MJ.  Approaching Death: Improving Care at the End of Life. Washington, DC: National Academies Press; 1997.
    14.
    Barnato  AE, Herndon  MB, Anthony  DL,  et al.  Are regional variations in end-of-life care intensity explained by patient preferences?: a study of the US Medicare population.  Med Care. 2007;45(5):386-393.PubMedGoogle ScholarCrossref
    15.
    Cohen  LM, Ruthazer  R, Moss  AH, Germain  MJ.  Predicting six-month mortality for patients who are on maintenance hemodialysis.  Clin J Am Soc Nephrol. 2010;5(1):72-79.PubMedGoogle ScholarCrossref
    16.
    Kurella Tamura  M, Covinsky  KE, Chertow  GM, Yaffe  K, Landefeld  CS, McCulloch  CE.  Functional status of elderly adults before and after initiation of dialysis.  N Engl J Med. 2009;361(16):1539-1547.PubMedGoogle ScholarCrossref
    17.
    Nordio  M, Limido  A, Maggiore  U, Nichelatti  M, Postorino  M, Quintaliani  G; Italian Dialysis and Transplantation Registry.  Survival in patients treated by long-term dialysis compared with the general population.  Am J Kidney Dis. 2012;59(6):819-828.PubMedGoogle ScholarCrossref
    18.
    O’Hare  AM, Bertenthal  D, Covinsky  KE,  et al.  Mortality risk stratification in chronic kidney disease: one size for all ages?  J Am Soc Nephrol. 2006;17(3):846-853.PubMedGoogle ScholarCrossref
    19.
    Schell  JO, Da Silva-Gane  M, Germain  MJ.  Recent insights into life expectancy with and without dialysis.  Curr Opin Nephrol Hypertens. 2013;22(2):185-192.PubMedGoogle ScholarCrossref
    20.
    Winkelmayer  WC, Glynn  RJ, Mittleman  MA, Levin  R, Pliskin  JS, Avorn  J.  Comparing mortality of elderly patients on hemodialysis versus peritoneal dialysis: a propensity score approach.  J Am Soc Nephrol. 2002;13(9):2353-2362.PubMedGoogle ScholarCrossref
    21.
    Davison  SN.  Pain in hemodialysis patients: prevalence, cause, severity, and management.  Am J Kidney Dis. 2003;42(6):1239-1247.PubMedGoogle ScholarCrossref
    22.
    Merkus  MP, Jager  KJ, Dekker  FW, de Haan  RJ, Boeschoten  EW, Krediet  RT.  Physical symptoms and quality of life in patients on chronic dialysis: results of the Netherlands Cooperative Study on Adequacy of Dialysis (NECOSAD).  Nephrol Dial Transplant. 1999;14(5):1163-1170.PubMedGoogle ScholarCrossref
    23.
    Parfrey  P, Vavasour  H, Bullock  M, Henry  S, Harnett  J, Gault  M.  Symptoms in end-stage renal disease: dialysis v transplantation.  Transplant Proc. 1987;19(4):3407-3409. PubMedGoogle Scholar
    24.
    Parfrey  PS, Vavasour  HM, Henry  S, Bullock  M, Gault  MH.  Clinical features and severity of nonspecific symptoms in dialysis patients.  Nephron. 1988;50(2):121-128.PubMedGoogle ScholarCrossref
    25.
    Devins  GM, Armstrong  SJ, Mandin  H,  et al.  Recurrent pain, illness intrusiveness, and quality of life in end-stage renal disease.  Pain. 1990;42(3):279-285.PubMedGoogle ScholarCrossref
    26.
    Curtin  RB, Bultman  DC, Thomas-Hawkins  C, Walters  BA, Schatell  D.  Hemodialysis patients’ symptom experiences: effects on physical and mental functioning.  Nephrol Nurs J. 2002;29(6):562-574.PubMedGoogle Scholar
    27.
    Watnick  S, Kirwin  P, Mahnensmith  R, Concato  J.  The prevalence and treatment of depression among patients starting dialysis.  Am J Kidney Dis. 2003;41(1):105-110.PubMedGoogle ScholarCrossref
    28.
    Yong  DS, Kwok  AO, Wong  DM, Suen  MH, Chen  WT, Tse  DM.  Symptom burden and quality of life in end-stage renal disease: a study of 179 patients on dialysis and palliative care.  Palliat Med. 2009;23(2):111-119.PubMedGoogle ScholarCrossref
    29.
    Murtagh  FE, Addington-Hall  J, Higginson  IJ.  The prevalence of symptoms in end-stage renal disease: a systematic review.  Adv Chronic Kidney Dis. 2007;14(1):82-99.PubMedGoogle ScholarCrossref
    30.
    Wong  SP, Kreuter  W, O’Hare  AM.  Healthcare intensity at initiation of chronic dialysis among older adults.  J Am Soc Nephrol. 2014;25(1):143-149.PubMedGoogle ScholarCrossref
    31.
    Wong  SP, Kreuter  W, Curtis  JR, Hall  YN, O’Hare  AM.  Trends in in-hospital cardiopulmonary resuscitation and survival in adults receiving maintenance dialysis.  JAMA Intern Med. 2015;175(6):1028-1035.PubMedGoogle ScholarCrossref
    32.
    O’Hare  AM, Rodriguez  RA, Hailpern  SM, Larson  EB, Kurella Tamura  M.  Regional variation in health care intensity and treatment practices for end-stage renal disease in older adults.  JAMA. 2010;304(2):180-186.PubMedGoogle ScholarCrossref
    33.
    Wachterman  MW, Pilver  C, Smith  D, Ersek  M, Lipsitz  SR, Keating  NL.  Quality of end-of-life care provided to patients with different serious illnesses.  JAMA Intern Med. 2016;176(8):1095-1102.PubMedGoogle ScholarCrossref
    34.
    Quan  H, Sundararajan  V, Halfon  P,  et al.  Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.  Med Care. 2005;43(11):1130-1139.PubMedGoogle ScholarCrossref
    35.
    Fisher  ES, Wennberg  DE, Stukel  TA, Gottlieb  DJ, Lucas  FL, Pinder  EL.  The implications of regional variations in Medicare spending, part 2: health outcomes and satisfaction with care.  Ann Intern Med. 2003;138(4):288-298.PubMedGoogle ScholarCrossref
    36.
    Barnato  AE, Farrell  MH, Chang  CC, Lave  JR, Roberts  MS, Angus  DC.  Development and validation of hospital “end-of-life” treatment intensity measures.  Med Care. 2009;47(10):1098-1105.PubMedGoogle ScholarCrossref
    37.
    Murray  AM, Arko  C, Chen  SC, Gilbertson  DT, Moss  AH.  Use of hospice in the United States dialysis population.  Clin J Am Soc Nephrol. 2006;1(6):1248-1255.PubMedGoogle ScholarCrossref
    38.
    Hogan  C; Medical Payment Advisory Commission (MedPAC). Spending in the last year of life and the impact of hospice on Medicare outlays. http://www.medpac.gov/docs/default-source/contractor-reports/spending-in-the-last-year-of-life-and-the-impact-of-hospice-on-medicare-outlays-updated-august-2015-.pdf?sfvrsn=0. Updated August 2015. Accessed July 6, 2017.
    39.
    Zuckerman  RB, Stearns  SC, Sheingold  SH.  Hospice use, hospitalization, and Medicare spending at the end of life.  J Gerontol B Psychol Sci Soc Sci. 2016;71(3):569-580.PubMedGoogle ScholarCrossref
    40.
    Taylor  DH  Jr, Ostermann  J, Van Houtven  CH, Tulsky  JA, Steinhauser  K.  What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program?  Soc Sci Med. 2007;65(7):1466-1478.PubMedGoogle ScholarCrossref
    41.
    Gozalo  P, Plotzke  M, Mor  V, Miller  SC, Teno  JM.  Changes in Medicare costs with the growth of hospice care in nursing homes.  N Engl J Med. 2015;372(19):1823-1831.PubMedGoogle ScholarCrossref
    42.
    Obermeyer  Z, Makar  M, Abujaber  S, Dominici  F, Block  S, Cutler  DM.  Association between the Medicare hospice benefit and health care utilization and costs for patients with poor-prognosis cancer.  JAMA. 2014;312(18):1888-1896.PubMedGoogle ScholarCrossref
    43.
    Wang  S, Hsu  SH, Huang  S, Soulos  PR, Gross  CP.  Longer periods of hospice service associated with lower end-of-life spending in regions with high expenditures.  Health Aff (Millwood). 2017;36(2):328-336.PubMedGoogle ScholarCrossref
    44.
    O’Hare  AM, Szarka  J, McFarland  LV,  et al.  Provider perspectives on advance care planning for patients with kidney disease: whose job is it anyway?  Clin J Am Soc Nephrol. 2016;11(5):855-866.PubMedGoogle ScholarCrossref
    45.
    Wong  SP, Vig  EK, Taylor  JS,  et al.  Timing of initiation of maintenance dialysis: a qualitative analysis of the electronic medical records of a national cohort of patients from the Department of Veterans Affairs.  JAMA Intern Med. 2016;176(2):228-235.PubMedGoogle ScholarCrossref
    46.
    Russ  AJ, Shim  JK, Kaufman  SR.  The value of “life at any cost”: talk about stopping kidney dialysis.  Soc Sci Med. 2007;64(11):2236-2247.PubMedGoogle ScholarCrossref
    47.
    Wachterman  MW, Marcantonio  ER, Davis  RB,  et al.  Relationship between the prognostic expectations of seriously ill patients undergoing hemodialysis and their nephrologists.  JAMA Intern Med. 2013;173(13):1206-1214.PubMedGoogle ScholarCrossref
    48.
    Lunney  JR, Lynn  J, Foley  DJ, Lipson  S, Guralnik  JM.  Patterns of functional decline at the end of life.  JAMA. 2003;289(18):2387-2392.PubMedGoogle ScholarCrossref
    49.
    Harris  P, Wong  E, Farrington  S,  et al.  Patterns of functional decline in hospice: what can individuals and their families expect?  J Am Geriatr Soc. 2013;61(3):413-417.PubMedGoogle ScholarCrossref
    50.
    Teno  JM, Weitzen  S, Fennell  ML, Mor  V.  Dying trajectory in the last year of life: does cancer trajectory fit other diseases?  J Palliat Med. 2001;4(4):457-464.PubMedGoogle ScholarCrossref
    ×