***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    ***EXAMPLES*** 
    Input: The purpose of this study was to describe the life-sustaining treatment preferences of  dialysis patients and to compare the acceptability of two generic and a disease-specific advance directive ( AD ) . Of 532 potentially eligible hemodialysis patients , 95 ( 17.9 % ) participated in the study . These patients completed two generic ( the Centre for Bioethics Living Will and the Medical Directive ) and one disease-specific ( the Dialysis Living Will ) AD in a r and omized cross-over trial . Treatment preferences were measured by using the Centre for Bioethics Living Will . Acceptability of the AD was measured by using a 13-item advance directive acceptability question naire ( ADAQ ) for each AD , and the  advance directive choice question naire ( ADCQ ) to elicit participants ' preferred AD . Twenty-five percent of the participants wanted to continue dialysis in case of severe stroke , 19 % in severe dementia , and 14 % in permanent coma . Averaged across treatments , proportions of participants wanting treatment in various health states were : current health ( 86 % ) , mild stroke ( 84 % ) , moderate stroke ( 60 % ) , severe stroke ( 21 % ) , mild dementia ( 78 % ) , moderate dementia ( 51 % ) , severe dementia ( 14 % ) , terminal illness ( 41 % ) , and permanent coma ( 10 % ) . Averaged across health states , proportions of participants wanting various types of treatment were :  dialysis  ( 58 % ) ,  antibiotics  ( 53 % ) , transfusion ( 53 % ) , surgery ( 48 % ) ,  cardiopulmonary resuscitation ( 48 % ) , respirator ( 47 % ) , and tube feeding ( 41 % ) . Mean ADAQ scores were : Dialysis Living Will , 71 % ; Centre for Bioethics Living Will , 70 % ; and Medical Directive , 60 % ( F = 8.27 , P < 0.001 ( repeat measures analysis of variance ) ; the Dialysis Living Will and Centre for Bioethics Living Will scored significantly higher than the Medical Directive ) . The proportion of participants who said they would choose to complete each AD was : Dialysis Living Will , 28 % ; Centre for Bioethics Living Will , 38 % ; Medical Directive , 31 % ; and unsure , 3 % ( chi 2 = 1.465 , df = 2 , P = 0.48 ) . In conclusion , twenty-five percent or less of hemodialysis patients want to continue dialysis  in three specific health states : severe stroke , severe dementia , and permanent coma . Health states and illness severity , far more than treatment descriptions , influence preferences . Dialysis patients should be offered a generic AD , and some generic AD are more acceptable than others . Only a minority of dialysis patients will complete any AD , but the completion of written AD forms is only one element in the process of advance care planning BACKGROUND African Americans ' beliefs about end-of-life care may differ from those of whites , but racial differences in advance care planning ( ACP ) outcomes are unknown . OBJECTIVE The aim of this study was to compare the efficacy of an ACP intervention on preparation for end-of-life decision making and post-bereavement outcomes for African Americans and whites on dialysis . METHOD A secondary analysis of data from a r and omized trial comparing an ACP intervention ( Sharing Patient 's Illness Representations to Increase Trust [ SPIRIT ] ) with usual care was conducted . There were 420 participants , 210 patient-surrogate dyads ( 67.4 % African Americans ) , recruited from 20 dialysis centers in North Carolina . The outcomes of preparation for end-of-life decision making included dyad congruence on goals of care , surrogate decision-making confidence , a composite of the two , and patient decisional conflict assessed at 2 , 6 , and 12 months post-intervention . Surrogate bereavement outcomes included anxiety , depression , and post-traumatic distress symptoms assessed at 2 weeks , and at 3 and 6 months after the patient 's death . RESULTS SPIRIT was superior to usual care in improving dyad congruence ( odds ration [ OR ] = 2.31 , p = 0.018 ) , surrogate decision-making confidence ( β = 0.18 , p = 0.021 ) , and the composite ( OR = 2.19 , p = 0.028 ) 2 months post-intervention , but only for African Americans . SPIRIT reduced patient decisional conflict at 6 months for whites and at 12 months for African Americans . Finally , SPIRIT was superior to usual care in reducing surrogates ' bereavement depressive symptoms for African Americans but not for whites ( β = -3.49 , p = 0.003 ) . CONCLUSION SPIRIT was effective in improving preparation for end-of-life decision-making and post-bereavement outcomes in African Americans Background We studied the distribution of causes of death in the CONTRAST cohort and compared the proportion of cardiovascular deaths with other population s to answer the question whether cardiovascular mortality is still the principal cause of death in end stage renal disease . In addition , we compared patients who died from the three most common death causes . Finally , we aim ed to study factors related to dialysis withdrawal . Methods We used data from CONTRAST , a r and omized controlled trial in 714 chronic hemodialysis patients comparing the effects of online hemodiafiltration versus low-flux hemodialysis .  Causes of death were adjudicated . The distribution of causes of death was compared to that of the Dutch dialysis registry and of the Dutch general population . Results In CONTRAST , 231 patients died on treatment . 32 % died from cardiovascular disease , 22 % due to infection and 23 % because of dialysis withdrawal . These proportions were similar to those in the Dutch dialysis registry and the proportional cardiovascular mortality was similar to that of the Dutch general population . cardiovascular death was more common in patients < 60 years . Patients who withdrew were older , had more co-morbidity and a lower mental quality of life at baseline . Patients who withdrew had much co-morbidity . 46 % died within 5 days after the last dialysis session . Conclusions Although the absolute risk of death is much higher , the proportion of cardiovascular deaths in a prevalent end stage renal disease population is similar to that of the general population . In older hemodialysis patients cardiovascular and non-cardiovascular death risk are equally important . Particularly the registration of dialysis withdrawal deserves attention . These findings may be partly limited to the Dutch population The prevalence of and mortality from chronic kidney disease ( CKD ) are high among African Americans .  Interventions to improve knowledge of the likely illness course and the benefits and risks of life-sustaining treatment at the end-of-life are needed for African Americans with CKD and their surrogate decision makers . Nineteen African Americans with stage 5 CKD and their surrogates were r and omized to either patient-centered advance care planning ( PC-ACP ) or usual care . PC-ACP dyads showed greater improvement in congruence in end-of-life treatment preferences ( p < .05 ) and higher perceived quality of communication ( p < .05 ) than do control dyads , but the two groups did not differ on other primary outcomes or acceptability measures , such as perceptions of cultural appropriateness . At posttest , 80 % of patients in the intervention group reported that they would choose to continue all life-sustaining treatments in a situation of a low chance of survival , whereas 28.6 % of patients in the control group reported that they would make that choice . At posttest , 90 % of patients in the intervention group reported that they would choose to undergo cardiopulmonary resuscitation  even if the chance of surviving the attempt would be low , whereas 57 % of patients in the control group reported that they would make that choice . PC-ACP can be effective in improving patient and surrogate congruence in end-of-life treatment preferences . However , the results suggest a need for further improvements in the intervention to enhance cultural appropriateness for African Americans with CKD CONTEXT Talking about death can be difficult . Without evidence that end-of-life discussion s improve patient outcomes , physicians must balance their desire to honor patient autonomy against a concern of inflicting psychological harm . OBJECTIVE To determine whether end-of-life discussion s with physicians are associated with fewer aggressive interventions . DESIGN , SETTING , AND PARTICIPANTS A US multisite , prospect i ve , longitudinal cohort study of patients with advanced cancer and their informal caregivers ( n = 332 dyads ) , September 2002-February 2008 . Patients were followed up from enrollment to death , a median of 4.4 months later . Bereaved caregivers ' psychiatric illness and quality of life was assessed a median of 6.5 months later . MAIN OUTCOME MEASURES Aggressive medical care ( eg , ventilation , resuscitation ) and hospice in the final week of life . Secondary outcomes included patients ' mental health and caregivers ' bereavement adjustment . RESULTS One hundred twenty-three of 332 ( 37.0 % ) patients reported having end-of-life discussion s before baseline . Such discussion s were not associated with higher rates of major depressive disorder ( 8.3 % vs 5.8 % ; adjusted odds ratio [ OR ] , 1.33 ; 95 % confidence interval [ CI ] , 0.54 - 3.32 ) , or more worry ( mean McGill score , 6.5 vs 7.0 ; P = .19 ) . After propensity-score weighted adjustment , end-of-life discussion s were associated with lower rates of ventilation ( 1.6 % vs 11.0 % ; adjusted OR , 0.26 ; 95 % CI , 0.08 - 0.83 ) , resuscitation ( 0.8 % vs 6.7 % ; adjusted OR , 0.16 ; 95 % CI , 0.03 - 0.80 ) , ICU admission ( 4.1 % vs 12.4 % ; adjusted OR , 0.35 ; 95 % CI , 0.14 - 0.90 ) , and earlier hospice enrollment ( 65.6 % vs 44.5 % ; adjusted OR , 1.65;95 % CI , 1.04 - 2.63 ) . In adjusted analyses , more aggressive medical care was associated with worse patient quality of life ( 6.4 vs 4.6 ; F = 3.61 , P = .01 ) and higher risk of major depressive disorder in bereaved caregivers ( adjusted OR , 3.37 ; 95 % CI , 1.12 - 10.13 ) , whereas longer hospice stays were associated with better patient quality of life ( mean score , 5.6 vs 6.9 ; F = 3.70 , P = .01 ) . Better patient quality of life was associated with better caregiver quality of life at follow-up ( beta = .20 ; P = .001 ) . CONCLUSIONS End-of-life discussion s are associated with less aggressive medical care near death and earlier hospice referrals . Aggressive care is associated with worse patient quality of life and worse bereavement adjustment The population -based dialysis rate in Ontario more than doubled between 1981 and 1992 ; yet there is concern about over-loaded facilities , delayed treatment and denial of dialysis through nonreferral and implicit rationing . A working party involving several stakeholders has been established in Ontario to address these issues . However , clinical policy making concerning dialysis services is impeded in all provinces by a lack of information . The causes of the moderately large variations in dialysis rates from province to province remain unclear . The exact extent and risks of delayed therapy have not been well defined . Dialysis protocol s vary inexplicably among centres , and cost data on different methods of providing dialysis are limited . Many steps could be taken in Ontario and other provinces to generate a better information base for planning and managing dialysis services . Predialysis clinics with outreach programs could help to ensure equitable access to this life-saving therapy . Criteria for choosing modes and intensities of renal-replacement therapy must be review ed . In areas of clear disagreement and uncertainty , patients could be r and omly assigned to different protocol s and outcomes studied . In areas of agreement , the criteria should be st and ardized . Advance directives may help ascertain patients ' wishes concerning the initiation or continuation of dialysis , and more accurate data on prognosis of different patient subgroups would aid in early identification of patients in a hopelessly deteriorating situation . Last , studies comparing the " output " ( e.g. , hours on hemodialysis ) per dollar of different dialysis units and modalities are also needed to ensure that all facilities are opening efficiently without compromising patient outcomes BACKGROUND Recent studies suggest that surrogate decision makers may be too optimistic about their end-of-life decision making abilities for loved ones . We examined surrogates ' decision making confidence with an emphasis on its linkages to their underst and ings of patients ' values and goals for end-of-life care . METHODS We used baseline data from a r and omized trial with 58 dyads of African-American dialysis patients and their surrogates who separately completed the Values of Life-Sustaining Treatment Outcomes and the Goals of Care documents . Surrogates also completed a Surrogate Decision Making Confidence Scale . RESULTS Overall , 60 % of surrogates were unsure how their loved ones would feel about continuing life-sustaining treatment , including dialysis , in at least one of the four outcomes presented in the Values of Life-Sustaining Treatment Outcomes . For goals of care near end of life , 67.2 % to 69.0 % of patients preferred comfort care only , but only 20 ( 34.5 
    Output:
    
We found sparse data that were assessed at suboptimal quality and therefore we were unable to formulate conclusions about whether advance care planning can influence numbers of hospital admissions and treatment required by people with ESKD , or if patients ' advance care directives were followed at end-of-life .