Advance Care Planning by or on Behalf of Peritoneal Dialysis Patients in Long-Term Care

Abstract

Advance care planning (ACP) is recommended for dialysis patients, especially those living in long-term-care facilities. Factors influencing ACP and the effect of plans on outcome are incompletely studied. We performed a retrospective chart review and follow-up of all peritoneal dialysis patients admitted to an academic nursing home between 1986 and 2000 and abstracted demographics, comorbidities, functional status as activities of daily living (ADL) score, documentation of ACP, and actual interventions. Of 109 patients, 108 had ACP; of these, patients participated in 71%. Plans to do not attempt resuscitation (DNAR) were associated with the presence of coronary disease (odds ratio, 4.24; confidence interval [CI], 1.49 to 12.02), lower ADL score (odds ratio, 1.22; CI, 1.08 to 1.38), and older age (odds ratio, 1.04; CI, 1.0007 to 1.09). Plans to do not hospitalize (DNH) were associated with ADL score only (odds ratio, 1.26; CI, 1.07 to 1.48). Patients with DNAR plans had poorer 3-, 6-, and 12-month survival (P < 0.02), but not after adjustment for age of 75 years or older, poor functional status, coronary disease, and decubiti. Plan compliance was limited. DNH plans were not associated with the likelihood of hospitalization (5 of 14 versus 42 of 93 patients) or length of stay (11.0 +/- 16.4 versus 8.0 +/- 15.1 days). Compliance with DNAR plans was determined for 81 of 108 patients. No patient with a DNAR plan had resuscitation attempted. Only 7 of 46 patients with plans to undergo resuscitation had it attempted. For these chronically ill patients, age and functional status strongly influence DNAR and DNH plans. ACP was not decisive in determining events during acute illness.