Conservative management and end-of-life care in an Australian cohort with ESRD

Morton, Rachael L., Webster, Angela C., McGeechan, Kevin, Howard, Kirsten, Murtagh, Fliss E. M., Gray, Nicholas A., Kerr, Peter G., Germain, Michael J. and Snelling, Paul (2016) Conservative management and end-of-life care in an Australian cohort with ESRD. Clinical Journal of the American Society of Nephrology, 11 12: 2195-2203. doi:10.2215/CJN.11861115


Author Morton, Rachael L.
Webster, Angela C.
McGeechan, Kevin
Howard, Kirsten
Murtagh, Fliss E. M.
Gray, Nicholas A.
Kerr, Peter G.
Germain, Michael J.
Snelling, Paul
Title Conservative management and end-of-life care in an Australian cohort with ESRD
Journal name Clinical Journal of the American Society of Nephrology   Check publisher's open access policy
ISSN 1555-9041
1555-905X
Publication date 2016-12-07
Sub-type Article (original research)
DOI 10.2215/CJN.11861115
Open Access Status Not yet assessed
Volume 11
Issue 12
Start page 2195
End page 2203
Total pages 9
Place of publication Washington, DC, United States
Publisher American Society of Nephrology
Language eng
Subject 2713 Epidemiology
2706 Critical Care and Intensive Care Medicine
2727 Nephrology
2747 Transplantation
Abstract Background and objectives We aimed to determine the proportion of patients who switched to dialysis after confirmed plans for conservative care and compare survival and end-of-life care among patients choosing conservative care with those initiating RRT. Design, setting, participants, & measurements A cohort study of 721 patients on incident dialysis, patients receiving transplants, and conservatively managed patients from 66 Australian renal units entered into the Patient Information about Options for Treatment Study from July 1 to September 30, 2009 were followed for 3 years. A two-sided binomial test assessed the proportion of patients who switched from conservative care to RRT. Cox regression, stratified by center and adjusted for patient and treatment characteristics, estimated factors associated with 3-year survival. Results In total, 102 of 721 patients planned for conservative care, andmedian age was 80 years old. Of these, 8% (95% confidence interval, 3% to 13%), switched to dialysis, predominantly for symptom management. Of 94 patients remaining on a conservative pathway, 18%were alive at 3 years. Of the total 721 patients, 247 (34%) died by study end. In multivariable analysis, factors associated with all-cause mortality included older age (hazard ratio, 1.55; 95% confidence interval, 1.36 to 1.77), baseline serumalbumin <3.0 versus 3.7-5.4 g/dl (hazard ratio, 4.31; 95%confidence interval, 2.72 to 6.81), and managementwith conservative care comparedwith RRT (hazard ratio, 2.18; 95% confidence interval, 1.39 to 3.40). Of 247 deaths, patients managed with RRT were less likely to receive specialist palliative care (26% versus 57%; P<0.001), more likely to die in the hospital (66% versus 42%; P<0.001) than home or hospice, and more likely to receive palliative care only within the last week of life (42% versus 15%; P<0.001) than those managed conservatively. Conclusions Survival after 3 years of conservative management is common, with relatively few patients switching to dialysis. Specialist palliative care services are used more frequently and at an earlier time point for conservatively managed patients, a practice associated with better symptom management and quality of life.
Formatted abstract
Background and objectives: We aimed to determine the proportion of patients who switched to dialysis after confirmed plans for conservative care and compare survival and end-of-life care among patients choosing conservative care with those initiating RRT.

Design, setting, participants, & measurements: A cohort study of 721 patients on incident dialysis, patients receiving transplants, and conservatively managed patients from 66 Australian renal units entered into the Patient Information about Options for Treatment Study from July 1 to September 30, 2009 were followed for 3 years. A two–sided binomial test assessed the proportion of patients who switched from conservative care to RRT. Cox regression, stratified by center and adjusted for patient and treatment characteristics, estimated factors associated with 3-year survival.

Results: In total, 102 of 721 patients planned for conservative care, and median age was 80 years old. Of these, 8% (95% confidence interval, 3% to 13%), switched to dialysis, predominantly for symptom management. Of 94 patients remaining on a conservative pathway, 18% were alive at 3 years. Of the total 721 patients, 247 (34%) died by study end. In multivariable analysis, factors associated with all-cause mortality included older age (hazard ratio, 1.55; 95% confidence interval, 1.36 to 1.77), baseline serum albumin <3.0 versus 3.7–5.4 g/dl (hazard ratio, 4.31; 95% confidence interval, 2.72 to 6.81), and management with conservative care compared with RRT (hazard ratio, 2.18; 95% confidence interval, 1.39 to 3.40). Of 247 deaths, patients managed with RRT were less likely to receive specialist palliative care (26% versus 57%; P<0.001), more likely to die in the hospital (66% versus 42%; P<0.001) than home or hospice, and more likely to receive palliative care only within the last week of life (42% versus 15%; P<0.001) than those managed conservatively.

Conclusions: Survival after 3 years of conservative management is common, with relatively few patients switching to dialysis. Specialist palliative care services are used more frequently and at an earlier time point for conservatively managed patients, a practice associated with better symptom management and quality of life.
Keyword Palliative medicine
Advance directives
Hospices
Kidney failure, chronic
Australia
Cohort studies
Death
Follow-up studies
Hospices
Humans
Kidney failure, chronic
Palliative care
Renal dialysis
Renal insufficiency, chronic
Renal replacement therapy
Serum albumin
Terminal care
Q-Index Code C1
Q-Index Status Provisional Code
Grant ID 1054216
PG2012
Institutional Status UQ

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Sub-type: Article (original research)
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