#3367 Recognition of end of life in patients with chronic hemodialysis in Lazio and use of palliative care: a registry study

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Abstract Background and Aims Approximately 60%–70% of patients on chronic hemodialysis (HD) die in hospital. This highlights the need to improve end-of-life (EoL) recognition and access to palliative care for patients with advanced kidney disease. The Lazio Regional Register of Dialysis and Transplantation (RRDTL) collects data on dialysis patients but has not been used to analyze access to palliative care. The use of palliative care in dialysis patients is not documented in dedicated registries. The aim of this study was to assess the recognition of the EoL in these patients. Withdrawal from dialysis close to death was considered as a proxy parameter for the recognition of the EoL. Method Were identified patients on chronic HD and their demographic, clinical and dialysis characteristics who died between 1 January 2009 and 31 December 2022 from the RRDTL. The selection of patients is described in Fig. 1. Non-delivery of dialysis in the last week of life was withdrawal due to recognition of end-of-life (group 1). Failure to recognise end-of-life was defined as dialysis in the 7 days before death (group 2). The choice of seven days is supported by literature data: in most patients death occurs between 7 and 15 days after discontinuation of dialysis. Results A total of 6,247 patients were identified; 1,009 (16.2%) had ceased dialysis treatment a minimum of seven days prior to death, while 5,238 had continued until death. In the cohort of 5,238 patients who did not undergo dialysis, 2,232 (42.6%) died in hospital, while 226 (4.3%) were discharged within five days of death. Figure 2 describes the characteristics of the patients who died. The distribution by age group, educational level, level of self-sufficiency, type of underlying nephropathy is not significantly different between the two groups. The likelihood of treatment discontinuation is higher in those who have been on dialysis for longer (6+ years 31.5% OR = 0.65 95% IC 0.55–0.77), those who have a vascular catheter (61.1%; OR = 1.24 95% IC 1.08–1.42) and those who have had at least one hospitalisation in the last year (16.9%, OR = 1.49 95% IC 1.20–1.85). Among comorbidities, only neoplasia was significantly increased in group 2 (P = 0.024). Hospitalisations in the last year are significantly more frequent among those who discontinue treatment in the last 15 days (3+ hospitalisations: 24.2% discontinuation no vs. 42.0% discontinuation yes). The difference is significant for all causes of hospitalisation in the study (Fig. 2). There were significant differences in the distribution of causes of death between the two groups (p-value 0.05). Conclusion This is the first study in Italy that has attempted to investigate the end-of-life in HD patients. In the absence of direct data on the use of palliative care in dialysis patients, we used proxy indicators for the recognition of the end-of-life, considering this essential for the activation of palliative care, obtaining a result in line with literature data. The study showed that in Lazio there is a lack of recognition of the EoL, with a medicalization of the EoL and the continuation of dialysis treatment until close to death. The creation of a palliative care register, the use of an advance care planning document the training of nephrologists and the creation of multidisciplinary teams with palliative care specialists must be a priority for the health system, both to improve the quality of life of patients in their last days and to promote more appropriate management of resources.

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