Frequency of Goals-of-Care Discussions among Veterans with Incident Kidney Failure

Among patients with a serious illness such as advanced kidney failure, advance care planning is vital, as patients in that population will confront decisions such as initiating maintenance dialysis. There are guidelines that encourage shared decision making to ensure alignment of treatment with patient preferences, particularly among elderly patients. Results of surveys suggest, however, that the quality of conversations regarding dialysis initiation is generally poor.

There are limited data suggesting that even after initiation of dialysis, discussions between patients and health providers regarding goals of care are infrequent; it is also unlikely that patient preferences regarding their treatment are recorded in an advance directive. Christina L. Bradshaw, MD, and colleagues conducted a retrospective cohort study to examine the documentation, content, and timing of discussions regarding dialysis preferences in a national cohort of older veterans with incident kidney failure. Results of the study were reported in the American Journal of Kidney Diseases [2020;75(5):744-752].

The researchers utilized Veterans Health Administration (VA) medical records linked to Medicare claims and the US Renal Data System to identify veterans ≥67 years of age with incident kidney failure between January 1, 2005, and December 31, 2010. Incident kidney failure was defined as progression to a sustained estimated glomerular filtration rate (eGFR) <15 mL/min/1.73 m2 using the Modification of Diet in Renal Disease Study equation or initiation of maintenance dialysis. Eligible patients had at least two eGFRs <15 mL/min/1.73 m2 at least 5 days apart including one outpatient measurement or one outpatient eGFR <15 mL/min/1.73 m2 and one VA or Medicare claim for end-stage kidney disease within a 12-month period.

The study exposures were demographic and facility characteristics, as well as predicted 6-month mortality risk following initiation of dialysis and documentation of preferences regarding resuscitation. The outcomes of interest were documented discussions of dialysis treatment and supportive care. Discussions about dialysis preference were defined as any documentation in provider notes with the veteran (or surrogate) about preparing for or initiating dialysis. A composite measure of supportive care was any discussion of conservative management without dialysis, hospice or palliative care, a trial of dialysis, or withdrawal from dialysis after initiation.

Following application of inclusion and exclusion criteria, the final study cohort included 349 veterans with incident kidney failure who initiated dialysis and 472 veterans with incident kidney failure who did not initiate dialysis. Of those who did initiate dialysis, 143 had a mortality risk score ≥5; of those who did not initiate dialysis, 163 had a mortality risk score ≥5. Compared with patients with a mortality risk score <5, those with a high score were older and more likely to be Black, have chronic conditions and functional impairments, reside in a nursing home, and have had nephrology care prior to developing incident kidney failure.

In the overall cohort, mean age was 80.9 years, 98.7% were men, and 70.2% were white. The participants were well distributed across geographic regions and 89.9% were seen in high-complexity VA facilities. Of the total cohort, 74% received some outpatient nephrology care prior to developing incident kidney failure. Documented discussions regarding discussions for resuscitation and dialysis were noted in 71.3% and 55.6% of patients, respectively. Overall, 32.4% of patients had a documented discussion of supportive care, but only 44% of patients at high risk for mortality with dialysis had such discussions noted in their records.

The pattern of documentation varied according to whether the patient ultimately started dialysis. Regardless of mortality risk, patients in the group that did not start dialysis were more likely to have documented discussions regarding dialysis, supportive care, and resuscitation (resuscitation discussions were documented most frequently) compared with patients in the group that did start dialysis. Among patients in the dialysis group with mortality risk score <5, <10% had a documented discussion about supportive care, and 40% had no documentation of any goals-of-care discussion. Among patients in the dialysis group with mortality risk score ≥5, 23% had documented discussion of supportive care and 24.% had no documentation of goals-of-care discussions.

Following adjustments, there were independent associations between facility region, outpatient nephrology care preceding incident kidney failure, and documentation of resuscitation preferences and the odds of having a documented dialysis or supportive care discussion. The practice of discussion varied by region, with the West less likely versus the rest of the country to document a dialysis-preferences discussion and more likely to document a supportive-care discussion.

While outpatient nephrology care was associated with higher odds of a documented dialysis discussion, it was also associated with lower odds of supportive-care discussions. Following multivariable adjustment, there was no association between mortality risk and the odds of a documented dialysis or supportive-care discussion.

The researchers cited some limitations to the study, including the possibility that the results are not generalizable to nonveteran populations, particularly those who receive care outside the VA health system, not capturing the type and specialty of the provider documenting the discussions, and the possibility that the medical records did not capture the full content or quality of the discussions between provider and patient.

In summary, the researchers said, “Discussions surrounding dialysis preferences, including supportive care, are infrequently documented and often decoupled from other aspects of advance care planning, which may result in dialysis decisions that are discordant with patient goals. A systematic redesign of the advance care planning process that encourages integration of these discussions into routine nephrology care is needed to ensure that the goals and preferences of persons with advanced kidney disease are better elicited and reflected in their treatment plans.”

Takeaway Points

  1. Researchers conducted a retrospective cohort study to examine the documentation, content, and timing of discussions about dialysis preferences between providers and patients with advanced kidney disease.
  2. In a cohort of US veterans with a mean age of 80.9 years, documented discussions regarding dialysis and resuscitation were noted in 55.6% and 77.1% of patients, respectively.
  3. The frequency of documentation varied by mortality risk and whether the patient ultimately initiated dialysis.