Failure of advance care planning to elicit patients' preferences for withdrawal from dialysis

Although withdrawal from dialysis is relatively common among dialysis patie nts, little is known about the patients' consideration of withdrawal during advance care planning. We studied a stratified random sample of 400 hemodi alysis patients in two geographic areas (all six dialysis units within 75 m iles of Morgantown, WV, and all nine dialysis units in Rochester, NY) by re viewing responses to a questionnaire addressing issues of advance care plan ning. Interviews were performed by trained interviewers during a routine he modialysis treatment. Fifty-one percent of the patients had completed an ad vance directive (29% had a living will and a health care proxy, 22% had a l iving will or proxy). Patients who had completed advance directives were mo re likely to have notified their decision makers of their roles (91% with a living will and health care proxy, 81% with a living will or proxy v 55% w ho had no advance directive; P < 0.01), Most patients had not discussed the ir wishes for specific interventions in the event of permanent coma: 41% ha d discussed mechanical ventilation; 35%, tube feedings; 25%, cardiopulmonar y resuscitation; and only 18% had discussed stopping dialysis. Patients who had completed a living will and proxy were most likely to have discussed e nd-of-life care, but stopping dialysis was the least often discussed interv ention, even in this patient subset. Sixty-nine percent had discussed mecha nical ventilation; 55%, tube feedings; 43%, cardiopulmonary resuscitation; and only 31% had discussed stopping dialysis (all P < 0.001). Although with drawal from dialysis is relatively common, it is rarely discussed in advanc e care planning by dialysis patients, Dialysis unit staff and nephrologists should address issues involving withdrawal from dialysis with their chroni c dialysjs patients. (C) 1999 by the National Kidney Foundation, Inc.