Many maintenance hemodialysis (HD) patients on Medicare are not receiving quality end-of-life care, new study findings suggest

In a cross-sectional study of 770,191 Medicare beneficiaries (mean age 74.8; 53.7% male) published online in JAMA Internal Medicine, 20% of HD patients received hospice. Of these, 41.5% entered too late — within 3 days of death — to benefit from the services, lead author Melissa Wachterman, MD, MSc, MPH, of the Veterans Affairs Boston Healthcare System and Brigham and Women’s Hospital in Boston, and colleagues reported online ahead of print in JAMA Internal Medicine. Current Medicare policy stipulates that disease-modifying therapies, including HD, must be stopped before a patient can enter hospice.

“Since most patients die within a week of terminating dialysis, this Medicare requirement effectively bars hospice entry until the final days of life for many of these patients,” Dr Wachterman stated in a Brigham and Women’s news release. “These short hospice stays make it very difficult for patients dying of kidney disease and their families to fully benefit from the expertise in pain and symptom management that hospice can offer and the emotional support that hospice can provide.”

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Compared with non-hospice patients, patients with hospice stays of 3 days or less had significantly higher rates of hospitalization (83.6% vs 74.4%) and intensive care unit admission (54% vs 51%) within a month of death. They were significantly less likely to die in the hospital (13.5% vs 55.1%) and receive intensive procedures (17.7% vs 31.6%).

Furthermore, Medicare costs in the last week of life were no lower with a short hospice stay ($10,756 vs $10,871). As the days in hospice increased, health care utilization and costs decreased, especially for those referred more than 15 days before death ($3221 for the last week of life).

“Provision of palliative care on initiation of hemodialysis would promote goal-concordant treatment decisions, support advance care planning, and help to address patients’ end-of-life care needs as their condition declines over time,” Margaret Schwarze, MD, Kate Schueller, MD, and R. Allan Jhagroo, MD, of the University of Wisconsin at Madison, wrote in an accompanying editorial. “This in combination with policy modifications that permit patients whose terminal illness is ESRD to maintain coverage for hemodialysis, along with their hospice benefit, has potential to expand access to hospice, improve end-of-life care, and reduce costs.”

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Wachterman MW, Hailpern SM, Keating NL, Kurella Tamura M, O’Hare AM. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. JAMA Intern Med. doi:10.1001/jamainternmed.2018.0256

Schwarze ML, Schueller K, and Jhagroo RA. Hospice use and end-of-life care for patients with end-stage renal disease: Too little, too late. JAMA Intern Med. doi:10.1001/jamainternmed.2018.1078

Medicare kidney failure patients enter hospice too late to reap full benefits. [Brigham and Women’s Hospital; April 30, 2018]