Murray Anne M, Arko Cheryl, Chen Shu-Cheng, Gilbertson David T, Moss Alvin H
Department of Medicine, Hennepin County Medical Center, Minneapolis, MN 55404, USA.
Clin J Am Soc Nephrol. 2006 Nov;1(6):1248-55. doi: 10.2215/CJN.00970306. Epub 2006 Sep 6.
Hospice is recognized for providing excellent end-of-life care but may be underused by dialysis patients. Hospice use and related outcomes were measured among dialysis patients, and factors that were associated with hospice use were identified. The 2-yr US Renal Data System dialysis patients who died between January 1, 2001, and December 31, 2002, and hospice claims from the Centers for Medicare & Medicaid Services were examined to measure prevalence, factors, and costs that were associated with dialysis withdrawal and hospice use. Of the 115,239 deceased patients, 21.8% withdrew from dialysis and 13.5% used hospice. Of those who withdrew, 41.9% used hospice. Failure to thrive was the most common reason for dialysis withdrawal (42.9%). On multivariable logistic regression analysis, factors that were significantly associated with hospice referral among patients who withdrew from dialysis were age, race, reason for withdrawal, ability to walk or transfer at dialysis initiation, and state of residence. Among patients who withdrew from dialysis and used hospice, median cost of per-patient care during the last week of life was $1858, compared with $4878 for nonhospice patients (P < 0.001); hospitalization costs accounted for most of that difference. Only 22.9% of dialysis hospice patients died in the hospital, compared with 69.0% of nonhospice patients (P < 0.001). A minority of dialysis patients use hospice, even among patients who withdrew from dialysis, whose death usually is certain. Increased hospice use may enable more dialysis patients to die at home, with substantial cost savings. Research regarding additional benefits of hospice care for dialysis patients is needed.
临终关怀因其提供优质的临终护理而得到认可，但可能未被透析患者充分利用。我们对透析患者的临终关怀使用情况及相关结果进行了测量，并确定了与临终关怀使用相关的因素。我们研究了2001年1月1日至2002年12月31日期间死亡的美国肾脏数据系统的2年透析患者，以及医疗保险和医疗补助服务中心的临终关怀索赔数据，以测量与透析撤机和临终关怀使用相关的患病率、因素和成本。在115239名死亡患者中，21.8%的患者停止了透析，13.5%的患者使用了临终关怀。在停止透析的患者中，41.9%的患者使用了临终关怀。身体机能衰退是透析撤机最常见的原因（42.9%）。多变量逻辑回归分析显示，在停止透析的患者中，与临终关怀转诊显著相关的因素包括年龄、种族、撤机原因、透析开始时的行走或转移能力以及居住州。在停止透析并使用临终关怀的患者中，生命最后一周的人均护理费用中位数为1858美元，而非临终关怀患者为4878美元（P<0.001）；住院费用占了大部分差异。只有22.9%的透析临终关怀患者在医院死亡，而非临终关怀患者为69.0%（P<0.001）。即使在那些停止透析、死亡通常已确定的患者中，也只有少数透析患者使用临终关怀。增加临终关怀的使用可能使更多透析患者在家中死亡，并大幅节省成本。需要对临终关怀对透析患者的其他益处进行研究。
