title: Advance Directives and End-of-Life Care among Nursing Home Residents Receiving Maintenance Dialysis.
abstract: OBJECTIVE
  Little is known about the relation between the content of advance directives and downstream treatment decisions among patients receiving maintenance dialysis. In this study, we determined the prevalence of advance directives specifying treatment limitations and/or surrogate decision-makers in the last year of life and their association with end-of-life care among nursing home residents.
  
  
  METHODS
  Using national data from 2006 to 2007, we compared the content of advance directives among 30,716 nursing home residents receiving dialysis to 30,825 nursing home residents with other serious illnesses during the year before death. Among patients receiving dialysis, we linked the content of advance directives to Medicare claims to ascertain site of death and treatment intensity in the last month of life.
  
  
  RESULTS
  In the last year of life, 36% of nursing home residents receiving dialysis had a treatment-limiting directive, 22% had a surrogate decision-maker, and 13% had both in adjusted analyses. These estimates were 13%-27%, 5%-11%, and 6%-13% lower, respectively, than for decedents with other serious illnesses. For patients receiving dialysis who had both a treatment-limiting directive and surrogate decision-maker, the adjusted frequency of hospitalization, intensive care unit admission, intensive procedures, and inpatient death were lower by 13%, 17%, 13%, and 14%, respectively, and hospice use and dialysis discontinuation were 5% and 7% higher compared with patients receiving dialysis lacking both components.
  
  
  CONCLUSIONS
  Among nursing home residents receiving dialysis, treatment-limiting directives and surrogates were associated with fewer intensive interventions and inpatient deaths, but were in place much less often than for nursing home residents with other serious illnesses.
authors.affiliation: Geriatric Research and Education Clinical Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, California.|Division of Nephrology, Stanford University School of Medicine, Palo Alto, California.
authors.forename: Manjula
authors.initials: M
authors.lastname: Kurella Tamura
authors.affiliation: Division of Nephrology, Stanford University School of Medicine, Palo Alto, California.
authors.forename: Maria E
authors.initials: ME
authors.lastname: Montez-Rath
authors.affiliation: Department of Medicine, Group Health Cooperative, Seattle, Washington.|Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington; and.
authors.forename: Yoshio N
authors.initials: YN
authors.lastname: Hall
authors.affiliation: Department of Medicine, Group Health Cooperative, Seattle, Washington.|Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington; and.
authors.forename: Ronit
authors.initials: R
authors.lastname: Katz
authors.affiliation: Department of Medicine, Group Health Cooperative, Seattle, Washington.|Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington; and.|Department of Hospital and Specialty Medicine, Veteran Affairs Puget Sound Health Care System, Seattle, Washington.
authors.forename: Ann M
authors.initials: AM
authors.lastname: O'Hare
mesh_terms: D024362:Advance Directive Adherence / Q000706:statistics & numerical data; D016223:Advance Directives / Q000706:statistics & numerical data*; D000368:Aged; D000369:Aged, 80 and over; D016887:Cardiopulmonary Resuscitation / Q000706:statistics & numerical data; D003657:Decision Making; D005260:Female; D005774:Gastrostomy / Q000706:statistics & numerical data; D006801:Humans; D007362:Intensive Care Units; D007441:Intubation, Gastrointestinal / Q000706:statistics & numerical data; D007676:Kidney Failure, Chronic / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009735:Nursing Homes; D010343:Patient Admission / Q000706:statistics & numerical data; D019727:Proxy / Q000706:statistics & numerical data*; D006435:Renal Dialysis; D012121:Respiration, Artificial / Q000706:statistics & numerical data; D013727:Terminal Care; D014481:United States
keywords: ESRD; Medicare; United States; advance directives; dialysis; hospice care; hospices; hospitalization; humans; inpatients; intensive care units; kidney failure, chronic; nursing homes; prevalence; renal dialysis; terminal care