Development and Validation of End-Of-Life Indicators for Dialysis Patients: A National Consensus Study in Taiwan

Background Identifying end-of-life (EOL) dialysis patients who may benefit from palliative care remains challenging in Asian healthcare settings where relational autonomy predominates over individual decision-making. We conducted a national consensus study in Taiwan during 2015-2016 to develop validated EOL indicators for dialysis patients, with findings subsequently validated through a decade of clinical experience including the COVID-19 pandemic. Methods We conducted a three-phase study: (1) systematic literature review; (2) two-round expert focus groups using the RAND/UCLA Appropriateness Method with 15 multidisciplinary experts; and (3) national survey of nephrologists from 624 dialysis facilities. Nine indicators were evaluated using 9-point Likert scales. Exploratory and confirmatory factor analyses identified latent constructs. Results Of 624 facilities, 337 responded (54.0%), yielding 254 nephrologists with complete responses (22.6% of registered specialists). Two indicators achieved high consensus (≥90%) for both hospice/dying care and advance care planning: prolonged mechanical ventilation (PMV) with dialysis in unconscious state, and PMV with multi-organ failure. Factor analysis identified three EOL patient subgroups: ventilator-dependent, critically ill, and functionally dependent, with acceptable CFA model fit (χ 2 = 27.6, df = 19, P = 0.091; RMSEA = 0.042; CFI = 0.99). ACP ratings yielded a two-factor structure with adequate fit (χ 2 = 35.5, df = 20, P = 0.018; RMSEA = 0.055). Conclusions Dialysis patients with PMV combined with unconsciousness or multi-organ failure represent the highest-consensus EOL indicators in Taiwan. These validated findings offer actionable guidance for hospice and end-of-life care referral within healthcare systems characterized by relational autonomy and collective family-patient-clinician deliberation.