(322) Dying While Dialyzed: The Need for Do-Not-Dialyze Orders at Life’s End

Introduction: In the intensive care unit (ICU), renal replacement therapy (RRT) is often provided to critically ill patients with end stage renal disease (ESRD) or acute kidney injury (AKI). For patients with poor prognosis, RRT does not appreciably improve their survival nor the quality of life. Patients and family members may not be aware that dialysis is as burdensome and invasive as mechanical ventilation and cardiopulmonary resuscitation, nor that patients can opt out of RRT, which may be a preferable choice especially when death is imminent. We sought to determine the prevalence of RRT and do-not-dialyze (DND) status among patients with poor prognoses in the ICU.

Methods: 200 ICU patients who died from September 2015 to March 2017 were enrolled with nurses who cared for them in the last week of their lives from the medical ICU and cardiac care unit of New York Presbyterian Hospital/Weill Cornell Medicine and the surgical ICU at the Brigham and Women’s Hospital. Nurse-perceived patients’ suffering was analyzed with medical decisions made by and for the patients in the last week of their lives, including do-not-resuscitate (DNR), do-not-intubate (DNI), DND and care withdrawal.

Results: A total of 67/200 (34%) patients received hemodialysis or continuous RRT in the last week of their lives. 6 (9%) patients required RRT due to ESRD and 61 (91%) patients for severe AKI. 5 of these 6 (83%) ESRD patients had advance directives in place, but none opted out of dialysis when death became imminent. 54/67 (80.6%) had a DNR order, 18/67 (26.9%) had an DNI order. When 22/67 (32.8%) patients eventually withdrew care, only 9/67 (13.4%) had documented DND with care withdrawal. Although the other 133 deceased patients did not require hemodialysis, only 1/133 ( < 1%) had documented DND. Our data indicated that the interviewed nurses considered those who received RRT in the last week of their lives suffered more with a lower mean overall quality of death score of 4.9 vs 6.0 and a lower mean peaceful death score of 5.5 vs 6.6, compared to those did not receive RRT.

Conclusions: While dialysis at the end of life does not significantly improve survival and may impose unnecessary suffering, DND is being underutilized relative to DNR/DNI. Greater attention to DND orders among patients with kidney failure is warranted.