Patients with end-stage renal disease receiving dialysis have a symptom burden and prognosis comparable to patients with incurable cancer. They frequently and increasingly receive intensive procedures near the end of life. Because the benefits of these interventions remain controversial,3 a key question is whether increasing intensity of end-of-life care reflects changes in the extent to which patient preferences are elicited and documented with advance directives. Nursing homes offer an important setting to evaluate advance directive use because they accept full responsibility for care during patient stay.

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