Clinical Nephrology – Epidemiology – Clinical Trials

Kidney International (2005) 68, 1282–1288; doi:10.1111/j.1523-1755.2005.00525.x

Factors associated with "do not resuscitate" orders and rates of withdrawal from hemodialysis in the international DOPPS

RACHEL B FISSELL, JENNIFER L BRAGG-GRESHAM, ANTONIO ALBERTO LOPES, JOSÉ MIGUEL CRUZ, SHUNICHI FUKUHARA, YASUSHI ASANO, WENDY WEINSTOCK BROWN, MARCIA L KEEN, FRIEDRICH K PORT and ERIC W YOUNG

Division of Nephrology, University of Michigan, and Department of Veterans Affairs Medical Center, Ann Arbor, Michigan; University Renal Research and Education Association, Ann Arbor, Michigan; Department of Medicine, Federal University of Bahia, Bahia, Brazil; Nephrology Service, Hospital General Universitario "La Fé," Valencia, Spain; Department of Epidemiology and Health Care Research, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan; Jichi Medical School and Sashima Red Cross Hospital, Ibaraki, Japan; Meharry Medical College, Vanderbilt University Medical Center, and Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee; Amgen, Inc., Thousand Oaks, California

Correspondence: Rachel B. Fissell, M.D., MS, University of Michigan Medical Center, Nephrology 111J, Veterans Affairs Department, 2215 Fuller Road, Ann Arbor, MI 48105–2303. E-mail: dopps@urrea.org

Received 20 December 2004; Revised 21 March 2005; Re-revised 6 April 2005; Accepted 21 April 2005.

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Abstract

Factors associated with "do not resuscitate" orders and rates of withdrawal from hemodialysis in the international DOPPS.

Background

 

Worldwide statistics on practice patterns regarding "do not resuscitate" (DNR) orders and patient withdrawal from hemodialysis have not been uniformly collected or analyzed.

Methods

 

Using data concerning adult hemodialysis patients randomly selected from 308 representative dialysis facilities in France, Germany, Italy, Japan, Spain, the United Kingdom, and the United States participating in the Dialysis Outcomes and Practice Patterns Study, DNR orders were tabulated at study entry from a prevalent cross-section of patients (N = 8615), using multivariate logistic regression to investigate characteristics associated with DNR status, Cox models to identify risk factors for withdrawal from hemodialysis, and scores from the mental component summary (MCS) and physical component summary (PCS) of the SF-36 to assess health-related quality of life.

Results

 

The United States had the highest prevalence of DNR orders (7.5%) and rate of withdrawal from hemodialysis (3.5 per 100 patient-years). Significant and independent associations with higher odds ratio (OR) of DNR were observed for older age (OR 1.16 per 10 years higher, P = 0.03) and nursing home residence (OR 2.34, P = 0.003), and with higher relative risk (RR) of withdrawal from dialysis (RR 2.38, P < 0.001). Patients who withdrew from hemodialysis died within a mean of 7.8 days and a median of 6.0 days.

Conclusion

 

The higher prevalence of DNR and rate of withdrawal from hemodialysis in the United States are consistent with its greater legal and cultural emphasis on patient autonomy. By showing characteristics associated with these outcomes, this study contributes to our understanding of why hemodialysis patients request DNR or withdraw from treatment.

Keywords:

Dialysis Outcomes and Practice Patterns Study (DOPPS), do not resuscitate orders, withdrawal from dialysis, hemodialysis, quality of life

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