When a patient with end-stage renal disease dies, the provider last responsible for their kidney care reports the death to the ESRD Medical Information System on this form. It records the date and place of death, treatment modality, coded primary and secondary causes, whether dialysis was discontinued and why, transplant history, and whether the patient was receiving palliative or hospice care.
The dialysis facility last responsible for the patient's maintenance or home dialysis completes it; for a transplant patient, the transplant center does. Item 18 names the attending physician, but the form has no physician signature.
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ESRD Death Notification
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The dialysis facility that was last responsible for the patient's maintenance dialysis, including home dialysis, completes it. If the patient had a kidney transplant, the transplant center is responsible. The form records the attending physician's printed name in item 18 and the name of the person submitting it.
The form must be completed within 2 weeks of the date of death. Facilities enter it in EQRS; a hard copy goes to the regional ESRD Network only when the electronic system cannot be used.
Answer item 14 on whether renal replacement therapy was discontinued, choose the circumstance (access failure, transplant failure, chronic failure to thrive, acute complication or other) and give the last dialysis date. Item 15 asks whether it followed a patient or family request and whether it related to hospice care.