Use of hospice in the United States dialysis population

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.