Palliative Care Discussion

Lower extremity amputation is common among patients with ESRD, and often portends a poor prognosis. However, little is known about end-of-life care among patients with ESRD who undergo amputation. Nearly one in 10 patients with end-stage renal disease (ESRD) undergoes lower-extremity amputation in their last year of life, according to a study published online Feb. 19 in the Journal of the American Society of Nephrology.
The researchers conducted a mortality follow-back study of Medicare beneficiaries; with ESRD who died in 2002 through 2014 to analyze patterns of lower extremity amputation in the last year of life compared; with a parallel cohort of beneficiaries without ESRD. They also examined the relationship between amputation and end-of-life care among the patients with ESRD.

Lower-extremity amputation

Catherine R. Butler, M.D., from the University of Washington in Seattle; and colleagues retrospectively assessed data for Medicare beneficiaries with ESRD (754,777 patients); who died in 2002 through 2014 and a parallel cohort of beneficiaries without ESRD (958,412 patients). The authors sought to examine patterns of lower-extremity amputation; in the last year of life.
The researchers found that lower-extremity amputation; but was more common among beneficiaries with ESRD versus those without ESRD (8 versus 1%). In adjusted analyses of only the patients with ESRD; but those who underwent lower-extremity amputation were substantially more likely to have been admitted to and to have had prolonged stays; but in acute and subacute care settings during their final year of life compared with those who had not undergone amputation.

Hospice services

The investigators also noted associations between amputation and a greater likelihood of dying in the hospital; dialysis discontinuation before death, and less time receiving hospice services. “These findings likely signal unmet palliative care; needs among seriously ill patients with ESRD who undergo amputation, as well as opportunities; to improve their care,” the authors write.

Overall, 8% of 754,777 beneficiaries with ESRD underwent at least one lower extremity amputation; in their last year of life compared with 1% of 958,412 beneficiaries without ESRD. Adjusted analyses of patients with ESRD showed that those who had undergone lower extremity amputation; were substantially more likely than those who was admitting to and to have had prolonged stays; in acute and subacute care settings during their final year of life. Amputation was also associated with a greater likelihood of dying in the hospital; dialysis discontinuation before death, and less time receiving hospice services.

Acute and subacute care settings

Nearly one in ten patients with ESRD undergoes lower extremity amputation in their last year of life. These patients have prolonged stays in acute and subacute health care; settings and appear to have limited access to hospice services. These findings likely signal unmet palliative care; needs among seriously ill patients with ESRD who undergo amputation as well as opportunities to improve their care.