Kidney specialists differ in their approaches to treatment decision-making with older patients with kidney failure, with many nephrologists not describing conservative management and some limiting patients’ role in decision-making, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN).

Understanding how differences in physicians’ perceptions of their role shape their discussions of the benefits and shortcomings of each approach may help improve care for patients.

Older adults begin dialysis more frequently than any other group in the United States, yet some regret initiating dialysis or think that they do not have a choice in the matter. This suggests that patients may be uninformed about their options and that kidney specialists may have significantly different approaches to explaining dialysis initiation and the decision-making process.

To investigate this issue, Keren Ladin, PhD, MSc (Tufts University) and her colleagues interviewed 35 nephrologists across the United States and asked about what they tell older patients who are facing dialysis decisions and enquired about their standard approach to these types of discussions.

Four different approaches to decision-making were apparent: paternalist, informative (patient-led), interpretive (with doctors as guides steering patients towards an optional treatment), and institutionalist (guided by institutional culture and incentives).

Five themes characterized differences between these approaches regarding how nephrologists prioritized the following:

• patient autonomy,
• patient engagement and deliberation (disclosing all options, presenting options neutrally, eliciting patient values, explicit treatment recommendation),
• the influence of institutional norms,
• the importance of clinical outcomes (such as survival, dialysis initiation),
• and physician role (educating patients, making decisions, pursuing active therapies, managing symptoms).

Paternalists and institutionalists viewed initiation of dialysis as a measure of success, while interpretive and informative nephrologists focused on patient engagement, quality of life, and aligning patient values with treatment.

The investigators also found that only one-third of nephrologists presented conservative management to patients, and all of these nephrologists followed either informative or interpretive approaches. The interpretive model best achieved shared decision-making between physician and patient.

“Our findings are important for two reasons,” said Dr. Ladin. “First, understanding the different ways that nephrologists approach decision-making, and identifying the approaches that empower patients to choose the treatment that is most aligned with their preferences may help reduce regret and depression associated with dialysis. Second, characterizing the spectrum of approaches to decision-making and identifying the one that best aligns with shared decision-making may help nephrologists better identify their approach and ways that they could improve to facilitate shared decision-making.”

In an accompanying Patient Voice editorial, Denise Eilers, BSN, RN, provides a perspective based on her dual roles as a registered nurse and a former home hemodialysis care partner for her husband. She noted that the study is especially timely given the large number of aging baby boomers in society. “That generation, of which I am a member, has been described in various terms such as goal oriented, self-sufficient, questioning and involved,” she wrote. “The sheer numbers of these older non-traditional adults will make it necessary to move the needle further toward shared decision-making as in the interpretive model. This study offers a guide from which to develop tools to facilitate discussions.”

Study co-authors include Renuka Pandya, PhD, Ronald D. Perrone, MD, Klemens B. Meyer, MD, Allison Kannam, Rohini Loke, Tira Oskoui, Daniel E Weiner, MD, MS, and John B. Wong, MD.

The article, entitled “Characterizing approaches to dialysis decision-making with older adults,” appeared online at http://cjasn.asnjournals.org/ on July 26 2018, doi: 10.2215/CJN.01740218.

The accompanying editorial, entitled “Person-Centered Approach to Deciding on Dialysis Treatment,” appeared online at http://cjasn.asnjournals.org/ on July 26, 2018.