Older patients and dialysis shared decision-making. Insights from an ethnographic discourse analysis of interviews and clinical interactions

Shared Decision-Making in Choosing Dialysis Modalities for Patients With Chronic Kidney Disease: An Evolutionary Concept Analysis

The concept of shared decision-making, which respects the autonomy of patients with chronic kidney disease in the process of choosing dialysis modalities, has been emphasized. Studies clearly defining the process of selecting dialysis methods for chronic kidney disease patients remain limited. Thus, this study aimed to conduct a Rodgers' evolutionary concept analysis of shared decision-making in choosing dialysis modalities among patients with chronic kidney disease. A comprehensive literature review was conducted using data from six electronic databases from 2013 to 2024. In total, 36 papers were included in this analysis. We found the seven key attributes of shared decision-making in dialysis modalities: "Setting goals for treatment sustainability and life after treatment," "Building a trusting and respectful relationship," "Developing a collaborative partnership," "Effective patient-doctor communication," "Choosing the right dialysis treatment options," "Making personalized and informed decisions" and "Voluntary participation and interactive process." Our knowledge can promote patient-centered communication and contribute to the development of tailored interventions for patients with chronic kidney disease and their family caregivers. TRIAL REGISTRATION: (PROSPERO) CRD42023453585 (https://www.crd.york.ac.uk/prospero/).

'It's basically 'have that or die'': a qualitative study of older patients' choices between dialysis and conservative kidney management

OBJECTIVES

Older people with kidney failure often have a limited range of treatment options, with few being well enough to receive a transplant. Instead, they either start dialysis or have 'conservative kidney management' (CKM). CKM involves care that focuses on managing the symptoms of kidney failure and maintaining quality of life in the absence of dialysis. The relative ability of dialysis and CKM to make older people live longer and feel better is uncertain. This study aimed to describe how older patients understand and decide between dialysis and CKM, as evidence suggests they may not be fully supported to make informed decisions between these treatments.

DESIGN

Qualitative study using semistructured interviews, analysed using inductive thematic analysis and constant comparative techniques.

SETTING

Three UK specialist kidney units.

PARTICIPANTS

Adults with estimated glomerular filtration rate (eGFR) <20 and aged over 80 years, irrespective of comorbidity or over 65 if living with two additional long-term conditions or frailty. Participants were purposively sampled to maximise clinicodemographic variation, and recruitment was continued until no new major themes were arising in the analysis.

RESULTS

Eight men and seven women with a median age of 81 (range 65-90), and a median eGFR of 12 were interviewed. Three themes were identified: (1) 'Do dialysis or die', where not having dialysis was equated with death; (2) The 'need' for dialysis, where haemodialysis was perceived as the default treatment and (3) Weighing-up quality and quantity of life, relating to the trade-offs made between treatment benefits and burdens. Participants appeared unlikely to recognise the uncertain survival benefits of dialysis.Our study took place in England and all the participants were white British. As culture and faith can play a large part in decisions involving life and death, our findings may not be applicable to those in other communities. Participants were recruited from three centres, limiting the breadth of approaches to kidney failure management.

CONCLUSIONS

For older people who face short lives irrespective of treatment for kidney failure, unfamiliarity with treatment options, the desire to live and the 'do or die' notion conspire to cast haemodialysis as inevitable, regardless of whether this is the most appropriate treatment. To best enable shared decision-making, clinicians should present kidney failure treatment options in an accurate and balanced way, and respect and support older people who are deciding whether to have CKM or dialysis. This includes articulating uncertainty and supporting patients to make trade-offs in relation to what is important to them.

Understanding Health Literacy in Fluid Management in Individuals Receiving Haemodialysis: A Directed Qualitative Content Analysis

AIMS

To describe the perspectives of individuals receiving haemodialysis regarding health literacy in fluid management.

DESIGN

A qualitative descriptive approach using directed content analysis of interviews from an explanatory mixed methods study.

METHODS

Semi-structured individual interviews were conducted from September 2020 to February 2021 with 28 individuals receiving haemodialysis who had attended a prior quantitative study. A directed qualitative content analysis approach was used to identify categories and subcategories emerging from the data.

RESULTS

Six categories of health literacy were identified: (1) active health management, (2) engagement with healthcare providers, (3) understanding and support from healthcare providers, (4) social support, (5) health information literacy and (6) navigation of the healthcare system.

CONCLUSIONS

Based on their real-life experience, individuals receiving haemodialysis have unique health literacy needs regarding fluid management. A comprehensive understanding of these unique needs is crucial in creating person-centered interventions to address inadequate fluid restriction.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Interventions to address inadequate fluid restriction should be person-centered, considering each individual's unique health literacy needs. This involves conducting a comprehensive assessment of individuals' health literacy needs, empowering individuals to actively engage in health, engaging the entire support network and facilitating health information literacy in line with individuals' preferences.

IMPACT

This study offers detailed insights into the health literacy needs related to fluid management in individuals undergoing haemodialysis. The findings could inform the development of person-centered fluid management strategies for these individuals.

REPORTING METHOD

We adhered to the Consolidated Criteria for Reporting Qualitative Research checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Communicating treatment options to older patients with advanced kidney disease: a conversation analysis study

BACKGROUND

Choosing to have dialysis or conservative kidney management is often challenging for older people with advanced kidney disease. While we know that clinical communication has a major impact on patients' treatment decision-making, little is known about how this occurs in practice. The OSCAR study (Optimising Staff-Patient Communication in Advanced Renal disease) aimed to identify how clinicians present kidney failure treatment options in consultations with older patients and the implications of this for patient engagement.

METHODS

An observational, multi-method study design was adopted. Outpatient consultations at four UK renal units were video-recorded, and patients completed a post-consultation measure of shared decision-making (SDM-Q-9). Units were sampled according to variable rates of conservative management. Eligible patients were ≥ 65 years old with an eGFR of ≤ 20 mls/min/1.73m2 within the last 6 months. Video-recordings were screened to identify instances where clinicians presented both dialysis and conservative management. These instances were transcribed in fine-grained detail and recurrent practices identified using conversation-analytic methods, an empirical, observational approach to studying language and social interaction.

RESULTS

110 outpatient consultations were recorded (105 video, 5 audio only), involving 38 clinicians (doctors and nurses) and 94 patients: mean age 77 (65-97); 61 males/33 females; mean eGFR 15 (range 4-23). There were 21 instances where clinicians presented both dialysis and conservative management. Two main practices were identified: (1) Conservative management and dialysis both presented as the main treatment options; (2) Conservative management presented as a subordinate option to dialysis. The first practice was less commonly used (6 vs. 15 cases), but associated with more opportunities in the conversation for patients to ask questions and share their perspective, through which they tended to evaluate conservative management as an option that was potentially personally relevant. This practice was also associated with significantly higher post-consultation ratings of shared decision-making among patients (SDM-Q-9 median total score 24 vs. 37, p = 0.041).

CONCLUSIONS

Presenting conservative management and dialysis as on an equal footing enables patient to take a more active role in decision-making. Findings should inform clinical communication skills training and education.

CLINICAL TRIAL NUMBER

No trial number as this is not a clinical trial.

Characterization of Telecare Conversations on Lifestyle Management and Their Relation to Health Care Utilization for Patients with Heart Failure: Mixed Methods Study

BACKGROUND

Telehealth interventions where providers offer support and coaching to patients with chronic conditions such as heart failure (HF) and type 2 diabetes mellitus (T2DM) are effective in improving health outcomes. However, the understanding of the content and structure of these interactions and how they relate to health care utilization remains incomplete.

OBJECTIVE

This study aimed to characterize the content and structure of telecare conversations on lifestyle management for patients with HF and investigate how these conversations relate to health care utilization.

METHODS

We leveraged real-world data from 50 patients with HF enrolled in a postdischarge telehealth program, with the primary intervention comprising a series of telephone calls from nurse telecarers over a 12-month period. For the full cohort, we transcribed 729 English-language calls and annotated conversation topics. For a subcohort (25 patients with both HF and T2DM), we annotated lifestyle management content with fine-grained dialogue acts describing typical conversational structures. For each patient, we identified calls with unusually high ratios of utterances on lifestyle management as lifestyle-focused calls. We further extracted structured data for inpatient admissions from 6 months before to 6 months after the intervention period. First, to understand conversational structures and content of lifestyle-focused calls, we compared the number of utterances, dialogue acts, and symptom attributes in lifestyle-focused calls to those in calls containing but not focused on lifestyle management. Second, to understand the perspectives of nurse telecarers on these calls, we conducted an expert evaluation where 2 nurse telecarers judged levels of concern and follow-up actions for lifestyle-focused and other calls (not focused on lifestyle management content). Finally, we assessed how the number of lifestyle-focused calls relates to the number of admissions, and to the average length of stay per admission.

RESULTS

In comparative analyses, lifestyle-focused calls had significantly fewer utterances (P=.01) and more dialogue acts (Padj=.005) than calls containing but not focused on lifestyle management. Lifestyle-focused calls did not contain deeper discussions on clinical symptoms. These findings indicate that lifestyle-focused calls entail short, intense discussions with greater emphasis on understanding patient experience and coaching than on clinical content. In the expert evaluation, nurse telecarers identified 24.2% (29/120) of calls assessed as concerning enough for follow-up. For these 29 calls, nurse telecarers were more attuned to concerns about symptoms and vitals (19/29, 65.5%) than lifestyle management concerns (4/29, 13.8%). The number of lifestyle-focused calls a patient had was modestly (but not significantly) associated with a lower average length of stay for inpatient admissions (Spearman ρ=-0.30; Padj=.06), but not with the number of admissions (Spearman ρ=-0.03; Padj=.84).

CONCLUSIONS

Our approach and findings offer novel perspectives on the content, structure, and clinical associations of telehealth conversations on lifestyle management for patients with HF. Hence, our study could inform ways to enhance telehealth programs for self-care management in chronic conditions.

Shared decision making in chronic kidney disease: a qualitative study of the impact of communication practices on treatment decisions for older patients

BACKGROUND

Effective interpersonal communication is critical for shared decision-making (SDM). Previous SDM communication training in nephrology has lacked context-specific evidence from ethnographic analysis of SDM interactions with older patients considering treatment options of end stage kidney disease (ESKD). This study explores communication strategies in SDM discussions in nephrology, specifically focusing on older patients considering dialysis as kidney replacement therapy (KRT).

METHODS

We conducted a qualitative study analysing naturally-occurring audio-recorded clinical interactions (n = 12) between Australian kidney doctors, patients aged 60+, and carers. Linguistic ethnography and qualitative socially-oriented functional approaches were used for analysis.

RESULTS

Two types of communication strategies emerged: (1) Managing and advancing treatment decisions: involving active checking of knowledge, clear explanations of options, and local issue resolution. (2) Pulling back: Deferring or delaying decisions through mixed messaging. Specifically for non-English speaking patients, pulling back was further characterised by communication challenges deferring decision-making including ineffective issue management, and reliance on family as interpreters. Age was not an explicit topic of discussion among participants when it came to making decisions about KRT but was highly relevant to treatment decision-making. Doctors appeared reluctant to broach non-dialysis conservative management, even when it appears clinically appropriate. Conservative care, an alternative to KRT suitable for older patients with co-morbidities, was only explicitly discussed when prompted by patients or carers.

CONCLUSIONS

The findings highlight the impact of different communication strategies on SDM discussions in nephrology. This study calls for linguistic-informed contextualised communication training and provides foundational evidence for nephrology-specific communication skills training in SDM for KRT among older patients. There is urgent need for doctors to become confident and competent in discussing non-dialysis conservative management. Further international research should explore naturally-occurring SDM interactions in nephrology with other vulnerable groups to enhance evidence and training integration.