Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington.
Department of Health Services, School of Public Health, University of Washington, Seattle.
JAMA Netw Open. 2019 Oct 2;2(10):e1913115. doi: 10.1001/jamanetworkopen.2019.13115.
Approximately 1 in 4 patients receiving maintenance dialysis for end-stage renal disease eventually stop treatment before death. Little is known about the association of stopping dialysis and quality of end-of-life care.
To evaluate the association of stopping dialysis before death with family-rated quality of end-of-life care and whether this association differed according to receipt of hospice services at the time of death.
DESIGN, SETTING, AND PARTICIPANTS: This survey study included data from 3369 patients who were treated with maintenance dialysis at 111 Department of Veterans Affairs medical centers and died between October 1, 2009, to September 30, 2015. Data set construction and analyses were conducted from September 2017 to July 2019.
Cessation of dialysis treatment before death.
Bereaved Family Survey ratings.
Among 3369 patients included, the mean (SD) age at death was 70.6 (10.2) years, and 3320 (98.5%) were male. Overall, 937 patients (27.8%) stopped dialysis before death and 2432 patients (72.2%) continued dialysis treatment until death. Patients who stopped dialysis were more likely to have been receiving hospice services at the time of death than patients who continued dialysis (544 patients [58.1%] vs 430 patients [17.7%]). Overall, 1701 patients (50.5%) had a family member who responded to the Bereaved Family Survey. In adjusted analyses, families were more likely to rate overall quality of end-of-life care as excellent if the patient had stopped dialysis (54.9% vs 45.9%; risk difference, 9.0% [95% CI, 3.3%-14.8%]; P = .002) or continued to receive dialysis but also received hospice services (60.5% vs 40.0%; risk difference, 20.5% [95% CI, 12.2%-28.9%]; P < .001).
This survey study found that families rated overall quality of end-of-life care higher for patients who stopped dialysis before death or continued dialysis but received concurrent hospice services. More work to prepare patients for end-of-life decision-making and to expand access to hospice services may help to improve the quality of end-of-life care for patients with end-stage renal disease.
大约每 4 名接受终末期肾病维持性透析的患者中，就有 1 名在死亡前最终停止治疗。对于停止透析与临终关怀质量之间的关联，人们知之甚少。
评估死亡前停止透析与家庭对临终关怀质量的评价之间的关联，以及这种关联是否因死亡时是否接受临终关怀服务而有所不同。
设计、地点和参与者：这项调查研究纳入了 2009 年 10 月 1 日至 2015 年 9 月 30 日期间在 111 个退伍军人事务部医疗中心接受维持性透析治疗并死亡的 3369 名患者的数据。数据集的构建和分析于 2017 年 9 月至 2019 年 7 月进行。
死亡前停止透析治疗。
丧亲家属调查评分。
在 3369 名患者中，死亡时的平均（SD）年龄为 70.6（10.2）岁，3320 名（98.5%）为男性。总体而言，937 名患者（27.8%）在死亡前停止了透析，2432 名患者（72.2%）继续透析直至死亡。与继续透析的患者相比，在死亡时接受临终关怀服务的停止透析的患者更多（544 名[58.1%] vs 430 名[17.7%]）。总体而言，有 1701 名患者（50.5%）的家属对丧亲家属调查做出了回应。在调整分析中，如果患者停止透析（54.9%比 45.9%；风险差异，9.0%[95%CI，3.3%-14.8%]；P=0.002）或继续接受透析但同时接受临终关怀服务（60.5%比 40.0%；风险差异，20.5%[95%CI，12.2%-28.9%]；P<0.001），家庭更有可能将临终关怀质量评为优秀。
这项调查研究发现，与死亡前停止透析或继续透析但同时接受临终关怀服务的患者相比，家庭对停止透析的患者的总体临终关怀质量评价更高。为终末期肾病患者进行更多的临终决策准备工作，并扩大临终关怀服务的可及性，可能有助于提高终末期肾病患者的临终关怀质量。
