Dialysis or hospice? Medicare policy that forces kidney disease patients to choose means only 20% get hospice

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End-of-life care is “categorically different” for patients receiving hemodialysis than for those with other terminal illnesses, a group of doctors said Monday in JAMA Internal Medicine.

The physicians' commentary was in coordination with research published in the same issue that found just 20% of maintenance dialysis patients enrolled in hospice — many of them for just three days or less.

A physician team from the University of Wisconsin-Madison called the access to hospice “startling” when compared to access for patients with cancer, COPD and dementia, all of whom enter hospice more often, receive care longer and often experience less invasive treatment in their last 30 days.

“The most obvious question to consider is whether hospice rules requiring discontinuation of ‘disease modifying' therapy for the patient's terminal illness (i.e. hemodialysis for patients with ESRD) prohibit timely access to hospice,” wrote lead author Margaret L. Schwarze, MD. “Given that dialysis termination has a well-defined and quite limited survival, patients and their families members may struggle with the decision to essentially ‘choose their own death.'”

Melissa Wachterman, M.D., with the section of General Internal Medicine at Boston's Veterans Affairs system told STAT that the policy "forces people to make a decision to stop dialysis in order to get hospice."

She suggested that allowing dialysis patients to shift to hospice without ending dialysis treatments would be more cost-effective.

Schwarze and her team called on the Centers for Medicare & Medicaid Services to conduct a clinical trial to see if a policy change could in fact improve quality of life for end-stage kidney disease patients while saving money.