Development and Acceptability of a Kidney Therapy Decision Aid for Patients Aged 75 Years and Older: A Design-Based Research Involving Patients, Caregivers, and a Multidisciplinary Team

Uncovering Patient and Caregiver Goals for Goal-Concordant Care in Kidney Therapy Decisions

CONTEXT

In kidney therapy (KT) decisions, goal-concordant decision-making is recognized to be important, yet alignment with patients' goals during dialysis initiation is not always achieved.

OBJECTIVES

To explore older patients' and caregivers' hopes, goals, and fears related to KT and communication of these elements with members of their health care team.

METHODS

The study included patients aged ≥75 years with an estimated glomerular filtration rate ≤25 mL/min/1.73 m2 and their caregivers enrolled in a palliative care intervention for KT decision-making. Patients and caregivers were asked open-ended questions about their hopes, goals, and fears related to KT decisions. A survey assessed if patients shared their goals with members of their health care team. Qualitative data underwent content analysis, supplemented by demographic descriptive statistics.

RESULTS

The mean age of patients (n = 26) was 82.7 (±5.7) years, and caregivers (n = 15) had a mean age of 66.4 (±13.7) years. Among the participants, 13 patients and 11 caregivers were women, and 20 patients and 12 caregivers were White. Four themes emerged: (1) Maintaining things as good as they are by avoiding dialysis-related burdens; (2) seeking longevity while avoiding dialysis; (3) avoiding pain, symptoms, and body disfigurement; and (4) deferring decision-making. Patients rarely had shared their goals with the key members of their health care team.

CONCLUSION

Patients and caregivers prioritize maintaining quality of life, deferring decision-making regarding dialysis, and avoiding dialysis-related burdens. These goals are often unshared with their family and health care teams. Given our aging population, urgent action is needed to educate clinicians to actively explore and engage with patient goals in KT decision-making.

Palliative Care Acceptability for Older Adults with Advanced CKD: A Qualitative Study of Patients and Nephrologists

Rationale & Objective

Older adults in the United States often receive kidney therapies that do not align with their goals. Palliative care (PC) specialists are experts in assisting patients with the goals of care discussions and decision support, yet views and experiences of older patients who have received PC while contemplating kidney therapy decisions and their nephrologists remain unexplored. We evaluated the acceptability of CKD-EDU, a PC-based kidney therapy decision support intervention for adults ≥75 years of age.

Study Design

Qualitative study.

Setting & Participants

Two trained research coordinators interviewed patients and nephrologists participating in the CKD-EDU study.

Analytical Approach

Three coders analyzed the qualitative data using a thematic analysis approach to identify salient themes pertaining to intervention acceptability.

Results

Patients (n = 19; mean age: 80 years) viewed the PC intervention favorably, noting PC physicians' excellent communication skills, whole-person care, and decision-making support, including comprehension of prognostic information. Nephrologists (n = 24; mean age) welcomed PC assistance in decision making, support for conservative kidney management, and symptom management; a minority voiced concerns about third-party involvement in their practice.

Limitations

Single-center study.

Conclusions

Overall, patients and nephrologists generally found the PC intervention to be acceptable. Future testing of the current PC-based decision support intervention in a larger randomized controlled trial for older people navigating kidney therapy decisions is needed.