Many SNF residents with kidney failure missing advanced directives, study shows

Less than half of nursing home residents with end-stage renal disease have completed advanced directives that can help reduce hospitalizations and intensive procedures in their last months of life, a new study shows.

Researchers from Stanford University and the University of Washington set out to find how advanced directives impacted end-of-life treatment decisions in those with kidney failure. Their study included more than 30,000 nursing home residents with end-stage renal disease, or ESRD, and another group of nearly 31,000 with other serious illnesses.

Their findings, published online Thursday in the Clinical Journal of the American Society of Nephrology, showed that 47% of residents with ESRD had some form of advanced directive completed, compared to between 59% and 70% of patients with other illnesses. Researchers also found 36% of residents with ESRD had some sort of treatment-limited directive, 22% had designated a decision-making surrogate, and 13% had both.

Those residents with kidney failure who had both a surrogate decision maker and treatment-limiting directives had lower rates of hospitalizations, admission to the intensive care unit, “intensive” medical procedures and inpatient death.

"Because the vast majority of patients with a treatment-limiting directive received care that was consistent with their advance directive, our findings suggest that efforts to increase engagement in advance care planning and expand the use of advance directives among patients receiving dialysis may offer untapped opportunities to better align end-of-life care with patient preferences and values,” said lead researcher Manjula Kurella Tamura, M.D., MPH.