Engaging in kidney transplant process may lead to more ‘aggressive’ end-of-life care
A study of Medicare beneficiaries showed those who participated in the transplant process received more intensive end-of-life care than other patients with end-stage kidney disease.
“Available evidence suggests that for patients with advanced kidney disease, hopes and expectations around kidney transplant strongly shape their prognostic expectations and may affect how they think about and plan for the future,” Catherine R. Butler, MD, of the University of Washington, and colleagues wrote. “Little is currently known about how engagement in the kidney transplant process — whether this be in the form of evaluation, waitlisting or receipt of a kidney transplant — might shape the care that patients receive as they approach the end of life.”
Suggesting that patients who participate in the transplant process are typically younger and have fewer comorbidities than others with ESKD, coupled with the fact that they have expressed interest to extend life through transplantation, the researchers hypothesized these patients would experience more intensive patterns of end-of-life care.
To test this theory, Butler and colleagues included adults with ESKD who died in the United States between 2005 and 2014 and compared measures of intensity of end-of-life care between those with varying exposure to the kidney transplant process (5% had a functioning kidney transplant; 3% had a failed transplant; 3% were removed from the waitlist; 3% were inactive on the waitlist; 2% were active on the waitlist; and 85% had never engaged in the transplant process).
Considered end-of-life care patterns within the last 30 days of life included admission to a hospital or admission to an ICU; receipt of cardiopulmonary resuscitation, mechanical ventilation, and/or artificial nutrition; or in-hospital mortality.
Results showed patients exposed to the transplant process were more likely to have been admitted to the hospital or to an intensive and/or coronary care unit within 30 days of death. They were also more likely to receive an invasive procedure and to experience in-hospital mortality than those who did not participate in the process.
In addition, researchers observed that a lower proportion of patients who were waitlisted at the time of death received hospice services than patients with ESKD who had no exposure to the transplant process (18% of those who were inactive, 12% who were active vs. 25% with no exposure), while also being less likely to discontinue dialysis before death (25% and 17% vs. 28%, respectively).
“Prior studies in the wider population with ESKD have described intensive patterns of end-of-life care focused on life extension that do not seem to reflect the kind of care many of these patients say they would want to receive if they were seriously ill or dying,” Butler and colleagues concluded. “Because there are strong defaults favoring use of aggressive interventions to prolong life in many U.S. health systems, our findings underline the importance of educating patients engaged in the transplant process about what to expect at the end of life and offering opportunities to engage in advance care planning.”