In the Journals

Patients with ESRD likely to undergo lower extremity amputation, better end-of-life care needed

Nearly one in 10 patients with ESRD undergo lower extremity amputation in their last year of life, while also having prolonged stays in health care settings and limited access to hospice services, according to a study published in the Journal of the American Society of Nephrology.

“These findings are concerning because despite wide-spread recognition that lower extremity amputation often means a poor prognosis for patients with ESRD, and that the event should prompt discussion about end-of-life preferences, this study suggests that end-of-life care for these seriously ill patients may not align with the kind of care that many seriously ill patients say they prefer — that is, to die at home and focus on comfort rather than life prolongation,” Catherine R. Butler, MD, of the University of Washington School of Medicine in Seattle, said in a press release.

To compare rates of lower extremity amputation between patients with and without ESRD — and to examine the relationship between amputation and end-of-life care among the patients with ESRD — researchers used data from the United States Renal Data System and identified Medicare beneficiaries who had been treated with maintenance dialysis or who received a kidney transplant before dying between January 2002 and December 2014. The cohort was further divided into those who did (n = 62,075) and those who did not (n = 692,702) undergo one or more lower extremity amputation in their last year of life. These individuals were compared with a parallel cohort of beneficiaries without ESRD who died during the same period (8,937 underwent lower extremity amputation; 949,475 did not).

Researchers also determined the percentage of patients with ESRD who were admitted to a hospital, ICU and/or skilled nursing facility during their last year of life and how much time was spent in these settings. Other factors that were considered included enrollment in hospice at time of death and whether patients died at home.

Researchers found that 8% of beneficiaries with ESRD and 1% of beneficiaries without ESRD underwent at least one lower extremity amputation in their last year of life.

In addition, it was determined that patients with ESRD who had undergone lower extremity amputation were more likely to have been admitted to acute and subacute care settings — and to have had prolonged stays there — than those who did not undergo amputation. Researchers also observed that amputation was associated with a greater likelihood of dying in the hospital, less time receiving hospice services and having dialysis discontinued before death.

“More work is needed to learn about the experiences of these seriously ill patients with ESRD who undergo amputation and to identify opportunities to improve their care,” Butler said in the release.

In a related commentary, Erica Perry, MSW, Sally Joy, BA, and Richard Swartz, MD, of the University of Michigan, wrote: “Nephrologists often fear that patients will misunderstand or perceive a lack of compassion if the topic of death and dying is brought up, and on a more personal note, nephrologists who have developed relationships with patients may dread losing ‘old friends.’ That being said, as chronic illness progresses, aggressive treatments prove less and less effective and a different approach is called for. This is a particularly helpful time for nephrologists to request input from others on the renal team (eg, social worker, nurse, dietician, technician) who may have talked with patients and families and gotten signals that it’s time to discuss quality of life and have an ‘enough is enough’ conference together. Nephrologists (physicians) too often think that they have to handle this alone, but collaboration with the renal team during this difficult phase of the journey can foster decision making and closure for all involved.” – by Melissa J. Webb

 

Disclosures: The authors report no relevant financial disclosures.

 

 

 

 

 

 

 

 

Nearly one in 10 patients with ESRD undergo lower extremity amputation in their last year of life, while also having prolonged stays in health care settings and limited access to hospice services, according to a study published in the Journal of the American Society of Nephrology.

“These findings are concerning because despite wide-spread recognition that lower extremity amputation often means a poor prognosis for patients with ESRD, and that the event should prompt discussion about end-of-life preferences, this study suggests that end-of-life care for these seriously ill patients may not align with the kind of care that many seriously ill patients say they prefer — that is, to die at home and focus on comfort rather than life prolongation,” Catherine R. Butler, MD, of the University of Washington School of Medicine in Seattle, said in a press release.

To compare rates of lower extremity amputation between patients with and without ESRD — and to examine the relationship between amputation and end-of-life care among the patients with ESRD — researchers used data from the United States Renal Data System and identified Medicare beneficiaries who had been treated with maintenance dialysis or who received a kidney transplant before dying between January 2002 and December 2014. The cohort was further divided into those who did (n = 62,075) and those who did not (n = 692,702) undergo one or more lower extremity amputation in their last year of life. These individuals were compared with a parallel cohort of beneficiaries without ESRD who died during the same period (8,937 underwent lower extremity amputation; 949,475 did not).

Researchers also determined the percentage of patients with ESRD who were admitted to a hospital, ICU and/or skilled nursing facility during their last year of life and how much time was spent in these settings. Other factors that were considered included enrollment in hospice at time of death and whether patients died at home.

Researchers found that 8% of beneficiaries with ESRD and 1% of beneficiaries without ESRD underwent at least one lower extremity amputation in their last year of life.

In addition, it was determined that patients with ESRD who had undergone lower extremity amputation were more likely to have been admitted to acute and subacute care settings — and to have had prolonged stays there — than those who did not undergo amputation. Researchers also observed that amputation was associated with a greater likelihood of dying in the hospital, less time receiving hospice services and having dialysis discontinued before death.

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“More work is needed to learn about the experiences of these seriously ill patients with ESRD who undergo amputation and to identify opportunities to improve their care,” Butler said in the release.

In a related commentary, Erica Perry, MSW, Sally Joy, BA, and Richard Swartz, MD, of the University of Michigan, wrote: “Nephrologists often fear that patients will misunderstand or perceive a lack of compassion if the topic of death and dying is brought up, and on a more personal note, nephrologists who have developed relationships with patients may dread losing ‘old friends.’ That being said, as chronic illness progresses, aggressive treatments prove less and less effective and a different approach is called for. This is a particularly helpful time for nephrologists to request input from others on the renal team (eg, social worker, nurse, dietician, technician) who may have talked with patients and families and gotten signals that it’s time to discuss quality of life and have an ‘enough is enough’ conference together. Nephrologists (physicians) too often think that they have to handle this alone, but collaboration with the renal team during this difficult phase of the journey can foster decision making and closure for all involved.” – by Melissa J. Webb

 

Disclosures: The authors report no relevant financial disclosures.