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Yun JY, Jeon DN, Jeon BJ, Kim EK. Factors influencing the decision-making process in breast reconstruction from the perspective of reconstructive surgeons: A qualitative study involving Korean plastic surgeons. J Plast Reconstr Aesthet Surg 2024; 93:72-80. [PMID: 38670035 DOI: 10.1016/j.bjps.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/05/2024] [Accepted: 04/05/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Little research has been conducted on factors influencing the decision-making process for immediate breast reconstruction (IBR) options from the perspective of reconstructive surgeons, despite its significant impact on doctor-patient communication and shared decision-making. This study aims to explore the multiple factors and the mechanisms by which they interact using a qualitative methodology. We also address potential barriers to shared decision-making in IBR. METHODS Semistructured interviews were conducted with a purposive sample of reconstructive surgeons. Thematic analysis was used to identify key influences on IBR decision-making process from the perspective of reconstructive surgeons. RESULTS Four major themes were identified: 1. Patient clinical scenarios; 2. Nonclinical practice environments; 3. Reconstructive surgeon preferences; and 4. Patient consultation. Reconstructive surgeons demonstrated diverse approaches to patient clinical scenarios. High-volume centers were significantly influenced by nonclinical factors such as scheduling and operating room allocation systems. Reconstructive surgeons often had strong personal preferences for specific IBR options, shaped by their expertise, experience, and clinical environment. Based on the preliminary decision, surgeons provided information with varying degrees of neutrality. Patients varied in their knowledge and participation, resulting in variation in the final decision authority among surgeons. CONCLUSIONS This study highlights the need to address nonclinical environmental constraints to improve shared decision-making process in IBR. Surgeons should recognize power imbalances in the doctor-patient relationship and be aware of their biases.
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Affiliation(s)
- Ji Young Yun
- Department of Plastic and Reconstructive Surgery, Busan Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Dong Nyeok Jeon
- Department of Plastic Surgery, Gangneung Asan Hospital, Gangneung, Korea
| | - Byung-Joon Jeon
- Department of Plastic and Reconstructive Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Key Kim
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Chang JH, Kim YC, Song SH, Kim S, Jo MW, Kim S. Shared Decision Making for Choosing renAl Replacement Therapy in Chronic Kidney Disease Patients (SDM-ART trial): study protocol for randomized clinical trial. Kidney Res Clin Pract 2023; 42:751-761. [PMID: 37098669 DOI: 10.23876/j.krcp.22.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 08/04/2022] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) should be educated about their condition so that they can initiate dialysis at the optimal time and make an informed choice between dialysis modalities. Shared decision-making (SDM) empowers patients to select their own treatment and improves patient outcomes. This study aimed to evaluate whether SDM affects the choice of renal replacement therapy among CKD patients. METHODS This is a multicenter, open-label, randomized, pragmatic clinical trial. A total of 1,194 participants with CKD who are considering renal replacement therapy were enrolled. The participants will be randomized into three groups in a 1:1:1 ratio: the conventional group, extensive informed decision-making group, and SDM group. Participants will be educated twice at months 0 and 2. Videos and leaflets will be provided to all patients. Patients in the conventional group will receive 5 minutes of education at each visit. The extensive informed decision-making group will receive more informed and detailed education using intensive learning materials for 10 minutes each visit. Patients in the SDM group will be educated for 10 minutes each visit according to illness perception and item-based analysis. The primary endpoint is the ratio of hemodialysis to peritoneal dialysis and kidney transplantation among the groups. Secondary outcomes include unplanned dialysis, economic efficiency, patient satisfaction, patient evaluation of the process, and patient adherence. DISCUSSION The SDM-ART is an ongoing clinical study to investigate the effect of SDM on the choice of renal replacement therapy in patients with CKD.
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Affiliation(s)
- Jae Hyun Chang
- Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang Heon Song
- Department of Internal Medicine and BioMedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Soojin Kim
- Division of Communication and Media, Ewha Womans University, Seoul, Republic of Korea
| | - Min-Woo Jo
- Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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Meijers B, Wellekens K, Montomoli M, Altabas K, Geter J, McCarthy K, Lobbedez T, Kazancioglu R, Thomas N. Healthcare professional education in shared decision making in the context of chronic kidney disease: a scoping review. BMC Nephrol 2023; 24:195. [PMID: 37386464 PMCID: PMC10308615 DOI: 10.1186/s12882-023-03229-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 06/02/2023] [Indexed: 07/01/2023] Open
Abstract
RATIONALE & OBJECTIVE Shared decision making (SDM) is a collaborative effort between healthcare professionals, individuals with CKD whereby clinical evidence, expected outcomes and potential side-effects are balanced with individual values and beliefs to provide the best mutually decided treatment option. Meaningful SDM is supported by effective training and education. We aimed to identify the available evidence on SDM training and education of healthcare professionals caring for people with chronic kidney disease. We aimed to identify existing training programs and to explore what means are used to evaluate the quality and effectiveness of these educational efforts. METHODOLOGY We performed a scoping review to study the effectiveness of training or education about shared decision making of healthcare professionals treating patients with kidney disease. EMBASE, MEDLINE, CINAHL and APA PsycInfo were searched. RESULTS After screening of 1190 articles, 24 articles were included for analysis, of which 20 were suitable for quality appraisal. These included 2 systematic reviews, 1 cohort study, 7 qualitative studies, and 10 studies using mixed methods. Study quality was varied with high quality (n = 5), medium quality (n = 12), and low quality (n = 3) studies. The majority of studies (n = 11) explored SDM education for nurses, and physicians (n = 11). Other HCP profiles included social workers (n = 6), dieticians (n = 4), and technicians (n = 2). Topics included education on SDM in withholding of dialysis, modality choice, patient engagement, and end-of-life decisions. LIMITATIONS We observed significant heterogeneity in study design and varied quality of the data. As the literature search is restricted to evidence published between January 2000 and March 2021, relevant literature outside of this time window has not been taken into account. CONCLUSIONS Evidence on training and education of SDM for healthcare professionals taking care of patients with CKD is limited. Curricula are not standardized, and educational and training materials do not belong to the public domain. The extent to which interventions have improved the process of shared-decision making is tested mostly by pre-post testing of healthcare professionals, whereas the impact from the patient perspective for the most part remains untested.
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Affiliation(s)
- Björn Meijers
- Department of Nephrology, Department of Microbiology, Immunology and Transplantation, UZ Leuven, KU Leuven, Leuven, Belgium.
- Department of Nephrology, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - Karolien Wellekens
- Department of Nephrology, Department of Microbiology, Immunology and Transplantation, UZ Leuven, KU Leuven, Leuven, Belgium
| | - Marco Montomoli
- Department of Nephrology, Hospital Clínico Universitario, Valencia, Spain
| | - Karmela Altabas
- Department of Nephrology and Dialysis, UC Sisters of Mercy, Zagreb, Croatia
| | | | | | - Thierry Lobbedez
- Department of Nephrology, University Hospitals of Caen, Caen, France
| | - Rumeyza Kazancioglu
- Department of Nephrology, Bezmialem Vakif University, Istanbul, Türkiye, Turkey
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Büdenbender B, Köther AK, Grüne B, Michel MS, Kriegmair MC, Alpers GW. When attitudes and beliefs get in the way of shared decision-making: A mediation analysis of participation preference. Health Expect 2023; 26:740-751. [PMID: 36639880 PMCID: PMC10010103 DOI: 10.1111/hex.13699] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/26/2022] [Accepted: 12/22/2022] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Certain sociodemographic characteristics (e.g., older age) have previously been identified as barriers to patients' participation preference in shared decision-making (SDM). We aim to demonstrate that this relationship is mediated by the perceived power imbalance that manifests itself in patients' negative attitudes and beliefs about their role in decision-making. METHODS We recruited a large sample (N = 434) of outpatients with a range of urological diagnoses (42.2% urooncological). Before the medical consultation at a university hospital, patients completed the Patients' Attitudes and Beliefs Scale and the Autonomy Preference Index. We evaluated attitudes as a mediator between sociodemographic factors and participation preference in a path model. RESULTS We replicated associations between relevant sociodemographic factors and participation preference. Importantly, attitudes and beliefs about one's own role as a patient mediated this relationship. The mediation path model explained a substantial proportion of the variance in participation preference (27.8%). Participation preferences and attitudes did not differ for oncological and nononcological patients. CONCLUSION Patients' attitudes and beliefs about their role determine whether they are willing to participate in medical decision-making. Thus, inviting patients to participate in SDM should encompass an assessment of their attitudes and beliefs. Importantly, negative attitudes may be accessible to change. Unlike stable sociodemographic characteristics, such values are promising targets for interventions to foster more active participation in SDM. PATIENT OR PUBLIC CONTRIBUTION This study was part of a larger project on implementing SDM in urological practice. Several stakeholders were involved in the design, planning and conduction of this study, for example, three authors are practising urologists, and three are psychologists with experience in patient care. In addition, the survey was piloted with patients, and their feedback was integrated into the questionnaire. The data presented in this study is based on patients' responses. Results may help to empower our patients.
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Affiliation(s)
- Björn Büdenbender
- Department of Psychology, School of Social Sciences, University of Mannheim, Mannheim, Germany
| | - Anja K Köther
- Department of Psychology, School of Social Sciences, University of Mannheim, Mannheim, Germany
| | - Britta Grüne
- Department of Urology and Urosurgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Maurice S Michel
- Department of Urology and Urosurgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Maximilian C Kriegmair
- Department of Urology and Urosurgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Georg W Alpers
- Department of Psychology, School of Social Sciences, University of Mannheim, Mannheim, Germany
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Abstract
The practice and clinical outcomes of peritoneal dialysis (PD) have demonstrated significant improvement over the past 20 years. The aim of this review is to increase awareness and update healthcare professionals on current PD practice, especially with respect to patient and technique survival, patient modality selection, pathways onto PD, understanding patient experience of care and use prior to kidney transplantation. These improvements have been impacted, at least in part, by greater emphasis on shared decision-making in dialysis modality selection, the use of advanced laparoscopic techniques for PD catheter implantation, developments in PD connecting systems, glucose-sparing strategies, and modernising technology in managing automated PD patients remotely. Evidence-based clinical guidelines such as those prepared by national and international societies such as the International Society of PD have contributed to improved PD practice underpinned by a recognition of the place of continuous quality improvement processes.
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Affiliation(s)
- Ayman Karkar
- Medical Affairs - Renal Care, Scientific Office, Baxter A.G., Dubai, United Arab Emirates
| | - Martin Wilkie
- Sheffield Teaching Hospitals NHS Foundation Trust, Herries Road, Sheffield, UK
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Ladin K, Frazier RS. The Elusive Promise of Shared Decision Making: A Step Forward. Am J Kidney Dis 2022; 79:623-625. [DOI: 10.1053/j.ajkd.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 10/02/2021] [Indexed: 11/11/2022]
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Yu X, Nakayama M, Wu MS, Kim YL, Mushahar L, Szeto CC, Schatell D, Finkelstein FO, Quinn RR, Duddington M. Shared Decision-Making for a Dialysis Modality. Kidney Int Rep 2022; 7:15-27. [PMID: 35005310 PMCID: PMC8720663 DOI: 10.1016/j.ekir.2021.10.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/14/2021] [Accepted: 10/18/2021] [Indexed: 02/06/2023] Open
Abstract
The prevalence of kidney failure continues to rise globally. Dialysis is a treatment option for individuals with kidney failure; after the decision to initiate dialysis has been made, it is critical to involve individuals in the decision on which dialysis modality to choose. This review, based on evidence arising from the literature, examines the role of shared decision-making (SDM) in helping those with kidney failure to select a dialysis modality. SDM was found to lead to more people with kidney failure feeling satisfied with their choice of dialysis modality. Individuals with kidney failure must be cognizant that SDM is an active and iterative process, and their participation is essential for success in empowering them to make decisions on dialysis modality. The educational components of SDM must be easy to understand, high quality, unbiased, up to date, and targeted to the linguistic, educational, and cultural needs of the individual. All individuals with kidney failure should be encouraged to participate in SDM and should be involved in the design and implementation of SDM approaches.
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Affiliation(s)
- Xueqing Yu
- Division of Nephrology, Guangdong Provincial People’s Hospital, Guangzhou, People’s Republic of China
- Correspondence: Xueqing Yu, Division of Nephrology, Guangdong Provincial People’s Hospital, 106th, Zhongshan Road II, Guangzhou 510080, People’s Republic of China.
| | | | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan
| | - Yong-Lim Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Lily Mushahar
- Department of Nephrology, Hospital Tuanku Ja'afar, Seremban, Malaysia
| | - Cheuk Chun Szeto
- Department of Medicine & Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Dori Schatell
- Medical Education Institute, Inc., Madison, Wisconsin, USA
| | | | - Robert R. Quinn
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Shi Y, Li W, Duan F, Pu S, Peng H, Ha M, Luo Y. Factors promoting shared decision-making in renal replacement therapy for patients with end-stage kidney disease: systematic review and qualitative meta-synthesis. Int Urol Nephrol 2021; 54:553-574. [PMID: 34159522 PMCID: PMC8831292 DOI: 10.1007/s11255-021-02913-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/06/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE Shared decision-making (SDM) about the type of renal replacement therapy to use is a matter of great importance involving patients, their families, and health treatment teams. This review aims to synthesize the volume of qualitative work explaining the factors influencing SDM regarding renal replacement therapy. METHODS A systematic review and qualitative meta-synthesis approach recommended by JBI was used, six databases were searched. Studies were qualitative or mixed research published since 2000, with a primary focus on patient experiences, perceptions and practices regarding which method to choose for renal replacement therapy in End-Stage Kidney Disease (ESKD) patients. All themes were analyzed and compared to the established connectedness. RESULTS A total of 1313 patients were enrolled in 32 studies focusing on factors associated with SDM regarding renal replacement therapy were included. All quality evaluations of the literature were medium to high. Four common themes were identified in our synthesis: (1) patient personal reasons, (2) family-related factors, (3) health care professional-related factors, and (4) social factors influence. CONCLUSION The model proposes pathways that could be explored further in future qualitative and quantitative studies and suggests that patients' beliefs, emotions, and awareness should be targeted alongside patients' decision-making practices to increase the efficacy of interventions. The majority of studies included in this review focus on older patients, and all report patients' perspectives. Further research is required to understand the family member perspectives on SMD of renal replacement therapy.
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Affiliation(s)
- Yu Shi
- School of Nursing, Third Military Medical University (Army Medical University), No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, People's Republic of China.,Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, People's Republic of China
| | - Wang Li
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, People's Republic of China
| | - Fangjian Duan
- School of Nursing, Third Military Medical University (Army Medical University), No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, People's Republic of China
| | - Shi Pu
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, People's Republic of China
| | - Hongmei Peng
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, People's Republic of China
| | - Mei Ha
- School of Nursing, Third Military Medical University (Army Medical University), No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, People's Republic of China
| | - Yu Luo
- School of Nursing, Third Military Medical University (Army Medical University), No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, People's Republic of China.
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Shaku F, Yada Y, Tsutsumi M, Kim WS. Characterising end-of-life decision-making of life-sustaining treatment among Japanese nurses. Int J Palliat Nurs 2021; 27:213-218. [PMID: 34169740 DOI: 10.12968/ijpn.2021.27.4.213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Often, nurses are closer to end-of-life (EOL) patients than other medical professionals, due to the time they spend with them at their bedside, which leads them to understand patients' care goals. AIMS To investigate the importance of EOL preferences by examining nurses' EOL decision-making regarding life-sustaining treatment (LST). METHODS In this cross-sectional study, 559 self-reported questionnaires of Japanese nurses were examined. Marital status, age and decision-making regarding LST for themselves were investigated. FINDINGS Unmarried participants from all age groups had a higher percentage of 'no preference for LST' than married groups. Differences between the percentages were higher in the 20s age group. Married participants increasingly preferred to receive no LST as their age increased, unlike single participants. CONCLUSION Marital status influences Japanese nurses' EOL decision-making regarding LST. Therefore, it is necessary to consider a patient's marital status to facilitate better decision-making.
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Affiliation(s)
- Fumio Shaku
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan; Department of Psychosomatic Internal Medicine, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Yoichi Yada
- Division of Pharmacology, Nihon University School of Medicine, Tokyo, Japan
| | | | - Woe Sook Kim
- College of Nursing Art and Science, University of Hyogo, Japan
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Martin DE, Muller E. In Defense of Patient Autonomy in Kidney Failure Care When Treatment Choices Are Limited. Semin Nephrol 2021; 41:242-252. [PMID: 34330364 DOI: 10.1016/j.semnephrol.2021.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Respect for patient autonomy is a primary ethical obligation of health care providers. In kidney health care, clinical practice recommendations commonly include strategies to promote shared decision making with patients and their families about treatment options to promote patient autonomy and improve patient outcomes. However, for many people with kidney failure, treatment options may be unavailable or inaccessible. In these circumstances some clinicians may act paternalistically and withhold information from patients because of a fear of causing harm or because clinicians believe that patient autonomy is not a relevant consideration. In this article, we reflect on the concept of autonomy in the context of clinical decision making in kidney failure care, with particular attention to resource-constrained settings and the disclosure of information to patients for whom treatment may be inaccessible. We examine and address key concerns that patient autonomy may be impossible, irrelevant, or harmful in the context of limited treatment choices, and discuss factors that may influence paternalistic practices in such settings. We conclude that respect for autonomy is intrinsically and instrumentally valuable, and argue that in neglecting patient autonomy in resource-constrained settings, clinicians may exacerbate and entrench the structural inequalities and health inequities they are committed to addressing.
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Affiliation(s)
| | - Elmi Muller
- Department of Surgery, University of Cape Town, Cape Town, South Africa
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Glyde M, Keane D, Dye L, Sutherland E. Patients' perceptions of their experience, control and knowledge of fluid management when receiving haemodialysis. J Ren Care 2019; 45:83-92. [PMID: 30938066 DOI: 10.1111/jorc.12275] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Person-centred care is increasingly promoted, empowering patients to become more involved in their treatment rather than being passive recipients of care (Barnes et al. 2013). Haemodialysis is typically required three times a week, with fluid management decision-making occurring at each treatment session (Ahmed et al. 2017). However, no research has yet explored how haemodialysis patients' perceptions of their fluid management may impact upon this decision-making. OBJECTIVES This study sought to explore patients' perceptions of their fluid management. METHOD DESIGN, PARTICIPANTS & APPROACH: Semi-structured interviews were conducted with 12 patients undergoing in-hospital haemodialysis treatment. These were digitally recorded one-to-one interviews to allow for verbatim transcription. The data was analysed by thematic analysis, generating thematic patterns across patients' experiences, control and knowledge of their fluid management. RESULTS Five themes were produced: determining who has the expertise, impediments affecting patients' lifestyle, additional difficulty of experiencing comorbidities, perceived quality of care, and establishing consistency. CONCLUSIONS Despite varied levels of patient participation in their treatment, overall there appears to be a limited understanding of specific areas of fluid management. The implications for further research and the development of shared-care are discussed.
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Affiliation(s)
- Megan Glyde
- School of Psychology, University of Leeds, Leeds, UK
| | - David Keane
- St. James' Hospital, Renal Medicine, Renal Research, Leeds, UK
| | - Louise Dye
- School of Psychology, University of Leeds, Leeds, UK
| | - Ed Sutherland
- School of Psychology, University of Leeds, Leeds, UK
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12
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Proof-of-Familiarity: A Privacy-Preserved Blockchain Scheme for Collaborative Medical Decision-Making. APPLIED SCIENCES-BASEL 2019. [DOI: 10.3390/app9071370] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The current healthcare sector is facing difficulty in satisfying the growing issues, expenses, and heavy regulation of quality treatment. Surely, electronic medical records (EMRs) and protected health information (PHI) are highly sensitive, personally identifiable information (PII). However, the sharing of EMRs, enhances overall treatment quality. A distributed ledger (blockchain) technology, embedded with privacy and security by architecture, provides a transparent application developing platform. Privacy, security, and lack of confidence among stakeholders are the main downsides of extensive medical collaboration. This study, therefore, utilizes the transparency, security, and efficiency of blockchain technology to establish a collaborative medical decision-making scheme. This study considers the experience, skill, and collaborative success rate of four key stakeholders (patient, cured patient, doctor, and insurance company) in the healthcare domain to propose a local reference-based consortium blockchain scheme, and an associated consensus gathering algorithm, proof-of-familiarity (PoF). Stakeholders create a transparent and tenable medical decision to increase the interoperability among collaborators through PoF. A prototype of PoF is tested with multichain 2.0, a blockchain implementing framework. Moreover, the privacy of identities, EMRs, and decisions are preserved by two-layer storage, encryption, and a timestamp storing mechanism. Finally, superiority over existing schemes is identified to improve personal data (PII) privacy and patient-centric outcomes research (PCOR).
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Scott J, Owen-Smith A, Tonkin-Crine S, Rayner H, Roderick P, Okamoto I, Leydon G, Caskey F, Methven S. Decision-making for people with dementia and advanced kidney disease: a secondary qualitative analysis of interviews from the Conservative Kidney Management Assessment of Practice Patterns Study. BMJ Open 2018; 8:e022385. [PMID: 30420346 PMCID: PMC6252646 DOI: 10.1136/bmjopen-2018-022385] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To explore dialysis decision-making for adults who lack capacity due to cognitive impairment, a common and under-recognised condition in those with advanced chronic kidney disease (CKD). DESIGN Secondary analysis of qualitative data collected during the Conservative Kidney Management Assessment of Practice Patterns Study programme of research was performed. Sixty semistructured interviews were conducted with multiprofessional team members from UK renal centres. Staff were asked about local facilities, the value of conservative kidney management (CKM), when and with whom CKM was discussed and how CKM could be improved. Thematic analysis was employed to identify, characterise and report on themes that emerged from the data, focused on the specific issues experienced by people with dementia. SETTING A purposive sample of nine UK renal centres differing in the scale of their CKM programmes. PARTICIPANTS Clinical directors of renal centres identified staff involved in CKM. Staff were asked to participate if they had experience of low clearance clinics or of caring for patients with advanced CKD (estimated glomerular filtration rate <20mL/min/1.732 or >65 years with end-stage kidney disease). RESULTS Two overarching themes were identified: factors taken into consideration during decision-making, and the process of decision-making itself. Comorbidity, social support, quality of life and the feasibility of dialysis were reported as factors pertinent to clinicians' decisions regarding suitability. The majority of renal centres practised multidisciplinary 'best interests' decision-making for those without capacity. Attitudes to advance care planning were divided. CONCLUSIONS In view of the prevalence of cognitive impairment among those with advanced CKD, we suggest consideration of routine assessment of cognition and capacity. In the UK, dialysis is initiated and continued for individuals with dementia and services should be adapted to meet the needs of this population.
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Affiliation(s)
- Jemima Scott
- Richard Bright Renal Unit, Southmead Hospital, Bristol, UK
- Department of Social & Community Medicine, University of Bristol, Bristol, UK
| | - Amanda Owen-Smith
- Department of Social & Community Medicine, University of Bristol, Bristol, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Bristol, UK
| | - Hugh Rayner
- Department of Renal Medicine, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Paul Roderick
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Ikumi Okamoto
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Geraldine Leydon
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Fergus Caskey
- Richard Bright Renal Unit, Southmead Hospital, Bristol, UK
- Department of Social & Community Medicine, University of Bristol, Bristol, UK
- UK Renal Registry, Bristol, UK
| | - Shona Methven
- UK Renal Registry, Bristol, UK
- Department of Renal Medicine, Aberdeen Royal Infirmary, Aberdeen, UK
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Harrison TG, Tam-Tham H, Hemmelgarn BR, James MT, Sinnarajah A, Thomas CM. Identification and Prioritization of Quality Indicators for Conservative Kidney Management. Am J Kidney Dis 2018; 73:174-183. [PMID: 30482578 DOI: 10.1053/j.ajkd.2018.08.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 08/29/2018] [Indexed: 01/28/2023]
Abstract
RATIONALE & OBJECTIVE Conservative kidney management is holistic patient-centered care for patients with kidney failure that focuses on delaying the progression of kidney disease and symptom management, without the provision of renal replacement therapy. Currently there is no consensus as to what constitutes high-quality conservative kidney management. We aimed to develop a set of quality indicators for the conservative management of kidney failure. STUDY DESIGN Nominal group technique and Delphi survey process. SETTING & PARTICIPANTS 16 patients and caregivers from Calgary, Canada, participated in 2 nominal group meetings. 91 multidisciplinary health care professionals from 10 countries took part in a Delphi process. ANALYTICAL APPROACH Nominal group technique study of patients and caregivers was used to identify and prioritize a list of quality indicators. A 4-round Delphi process with health care professionals was used to rate the quality indicators until consensus was reached (defined as a mean rating on the Likert scale ≥7.0 and percent agreement >75%). Quality indicators that met criteria for consensus inclusion in the Delphi survey were ranked, and comparisons were made with nominal group priorities. RESULTS 99 quality indicators met consensus criteria for inclusion. The most highly rated quality indicator in the Delphi process was the "percentage of patients that die in the place they desire." There was significant discordance between priorities of the nominal groups with that of the Delphi survey, with only 1 quality indicator being shared on each groups' top 10 list of quality indicators. LIMITATIONS Participants were largely from high-income English-speaking countries, and most already had structured conservative kidney management programs in place, all potentially limiting generalizability. CONCLUSIONS Quality of conservative kidney management care is important to patients, caregivers, and health care professionals. However, discordant quality indicator priorities between groups suggested that care providers delivering conservative kidney management may not prioritize what is most important to those receiving this care. Conservative kidney management programs and health care providers can improve the applicability of this consensus-based quality indicator list to their program by further developing and evaluating it for use in their program.
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Affiliation(s)
- Tyrone G Harrison
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Helen Tam-Tham
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Brenda R Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Matthew T James
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Aynharan Sinnarajah
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Chandra M Thomas
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Noble H, Brazil K, Burns A, Hallahan S, Normand C, Roderick P, Thompson C, Maxwell P, Yaqoob M. Clinician views of patient decisional conflict when deciding between dialysis and conservative management: Qualitative findings from the PAlliative Care in chronic Kidney diSease (PACKS) study. Palliat Med 2017; 31:921-931. [PMID: 28417662 DOI: 10.1177/0269216317704625] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Only a paucity of studies have addressed clinician perspectives on patient decisional conflict, in making complex decisions between dialysis and conservative management (renal supportive and palliative care). AIM To explore clinician views on decisional conflict in patients with end-stage kidney disease. DESIGN Interpretive, qualitative study. SETTING AND PARTICIPANTS As part of the wider National Institute for Health Research, PAlliative Care in chronic Kidney diSease study, semi-structured interviews were conducted with clinicians (nephrologists n = 12; 7 female and clinical nurse specialists n = 15; 15 female) across 10 renal centres in the United Kingdom. Interviews took place between April 2015 and October 2016 and a thematic analysis of the interview data was undertaken. RESULTS Three major themes with associated subthemes were identified. The first, 'Frequent changing of mind regarding treatment options', revealed how patients frequently altered their treatment decisions, some refusing to make a decision until deterioration occurred. The second theme, 'Obligatory beneficence', included clinicians helping patients to make informed decisions where outcomes were uncertain. In weighing up risks and benefits, and the impact on patients, clinicians sometimes withheld information they thought might cause concern. Finally, 'Intricacy of the decision' uncovered clinicians' views on the momentous and brave decision to be made. They also acknowledged the risks associated with this complex decision in giving prognostic information which might be inaccurate. LIMITATIONS Relies on interpretative description which uncovers constructed truths and does not include interviews with patients. CONCLUSION Findings identify decisional conflict in patient decision-making and a tension between the prerequisite for shared decision-making and current clinical practice. Clinicians also face conflict when discussing treatment options due to uncertainty in equipoise between treatments and how much information should be shared. The findings are likely to resonate across countries outside the United Kingdom.
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Affiliation(s)
- Helen Noble
- 1 School of Nursing and Midwifery Queen's University Belfast, Belfast, UK
| | - Kevin Brazil
- 1 School of Nursing and Midwifery Queen's University Belfast, Belfast, UK.,2 Queen's University Belfast, Belfast, UK
| | | | | | - Charles Normand
- 5 Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | | | - Colin Thompson
- 7 Northern Ireland Kidney Patient Association, Belfast, UK
| | - Peter Maxwell
- 8 School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.,9 Regional Nephrology Unit, Belfast City Hospital, Belfast, UK
| | - Magdi Yaqoob
- 10 William Harvey Research Institute, Queen Mary University of London, London, UK.,11 Renal Unit, The Royal London Hospital, London, UK
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16
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Chen NH, Lin YP, Liang SY, Tung HH, Tsay SL, Wang TJ. Conflict when making decisions about dialysis modality. J Clin Nurs 2017; 27:e138-e146. [PMID: 28543737 DOI: 10.1111/jocn.13890] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2017] [Indexed: 02/02/2023]
Abstract
AIMS AND OBJECTIVES To explore decisional conflict and its influencing factors on choosing dialysis modality in patients with end-stage renal diseases. The influencing factors investigated include demographics, predialysis education, dialysis knowledge, decision self-efficacy and social support. BACKGROUND Making dialysis modality decisions can be challenging for patients with end-stage renal diseases; there are pros and cons to both haemodialysis and peritoneal dialysis. Patients are often uncertain as to which one will be the best alternative for them. This decisional conflict increases the likelihood of making a decision that is not based on the patient's values or preferences and may result in undesirable postdecisional consequences. Addressing factors predisposing patients to decisional conflict helps to facilitate informed decision-making and then to improve healthcare quality. DESIGN A predictive correlational cross-sectional study design was used. METHODS Seventy patients were recruited from the outpatient dialysis clinics of two general hospitals in Taiwan. Data were collected with study questionnaires, including questions on demographics, dialysis modality and predialysis education, the Dialysis Knowledge Scale, the Decision Self-Efficacy scale, the Social Support Scale, and the Decisional Conflict Scale. RESULTS The mean score on the Decisional Conflict Scale was 29.26 (SD = 22.18). Decision self-efficacy, dialysis modality, predialysis education, professional support and dialysis knowledge together explained 76.4% of the variance in decisional conflict. CONCLUSIONS Individuals who had lower decision self-efficacy, did not receive predialysis education on both haemodialysis and peritoneal dialysis, had lower dialysis knowledge and perceived lower professional support reported higher decisional conflict on choosing dialysis modality. RELEVANCE TO CLINICAL PRACTICE When providing decisional support to predialysis stage patients, practitioners need to increase patients' decision self-efficacy, provide both haemodialysis and peritoneal dialysis predialysis education, increase dialysis knowledge and provide professional support.
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Affiliation(s)
- Nien-Hsin Chen
- Department of Nursing, Jen-Teh Junior College of Medicine, Nursing and Management, Shalunhu, Houlong Township, Miaoli County, Taiwan
| | - Yu-Ping Lin
- Department of Nursing, Oriental Institute of Technology, Taipei, Taiwan
| | - Shu-Yuan Liang
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Heng-Hsin Tung
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | | | - Tsae-Jyy Wang
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
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17
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McPherson L, Basu M, Gander J, Pastan SO, Mohan S, Wolf MS, Chiles M, Russell A, Lipford K, Patzer RE. Decisional conflict between treatment options among end-stage renal disease patients evaluated for kidney transplantation. Clin Transplant 2017; 31. [PMID: 28457025 PMCID: PMC10067135 DOI: 10.1111/ctr.12991] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2017] [Indexed: 11/26/2022]
Abstract
Although kidney transplantation provides a significant benefit over dialysis, many patients with end-stage renal disease (ESRD) are conflicted about their decision to undergo kidney transplant. We aimed to identify the prevalence and characteristics associated with decisional conflict between treatment options in ESRD patients presenting for transplant evaluation. Among a cross-sectional sample of patients with ESRD (n=464) surveyed in 2014 and 2015, we assessed decisional conflict through a validated 10-item questionnaire. Decisional conflict was dichotomized into no decisional conflict (score=0) and any decisional conflict (score>0). We investigated potential characteristics of patients with decisional conflict using bivariate and multivariable logistic regression. The overall mean age was 50.6 years, with 62% male patients and 48% African American patients. Nearly half (48.5%) of patients had decisional conflict regarding treatment options. Characteristics significantly associated with decisional conflict in multivariable analysis included male sex, lower educational attainment, and less transplant knowledge. Understanding characteristics associated with decisional conflict in patients with ESRD could help identify patients who may benefit from targeted interventions to help patients make informed, value-based, and supported decisions when deciding how to best treat their kidney disease.
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Affiliation(s)
- Laura McPherson
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Mohua Basu
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jennifer Gander
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Stephen O Pastan
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Sumit Mohan
- Renal and Pancreatic Transplant Program, Columbia University Medical Center, New York, NY, USA
| | - Michael S Wolf
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mariana Chiles
- Renal and Pancreatic Transplant Program, Columbia University Medical Center, New York, NY, USA
| | - Allison Russell
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kristie Lipford
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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18
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Jayanti A, Foden P, Brenchley P, Wearden A, Mitra S. The Burden of Cognitive Impairment in Patients With End-Stage Renal Disease and Impact on Dialysis Modality Choice. Kidney Int Rep 2016; 1:240-249. [PMID: 29142928 PMCID: PMC5678624 DOI: 10.1016/j.ekir.2016.07.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/16/2016] [Accepted: 07/27/2016] [Indexed: 02/06/2023] Open
Abstract
Introduction Kidney disease is associated with significant cognitive dysfunction. Subjective reports of cognitive ability have not been studied extensively in chronic kidney disease. We investigated the association between objective and subjective cognitive functions in predialysis patients and their association with self-care dialysis modality choice. Methods Cross-sectional data from the Barriers to Successful Implementation of Care in Home Haemodialysis study were used for the study of cognition in 220 predialysis patients. The data were used to ascertain the demographics, clinical, laboratory, and neuropsychometric variables. The latter includes Trail Making Tests (TMT) parts A and B, Modified Mini Mental State Examination, and metacognition questionnaire for subjective assessment of one's cognitive ability. The outcome variable was fully assisted and self-care dialysis modality choice. Results Within the study cohort, 90 patients chose fully assisted hemodialysis and 114 patients chose self-care dialysis. The median Modified Mini Mental State Examination, TMT part A, and TMT part B scores were greater for the assisted versus the self-care group. Metamemory was not significantly different between groups, but the metaconcentration score was significantly worse in the group choosing assisted dialysis. Higher (i.e., better) metaconcentration scores were significantly associated with the self-care modality choice in the univariate and hierarchical regression analyses. Adjusted and unadjusted analyses showed a significant association between perceived concentration and TMT part B scores (P < 0.01). With every 1.6-minute increase in TMT part B score, there was a 1-unit reduction in metaconcentration score, and the latter was associated with 20% lower odds of choosing self-care dialysis over a fully assisted dialysis modality. Discussion Patients' self-perception of cognitive ability is a significant predictor of self-care dialysis modality choice. Subjective report of "metaconcentration" is also strongly associated with poorer outcome on the TMT part B.
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Affiliation(s)
- A Jayanti
- Renal Research Division, Central Manchester University Hospitals NHS Trust, Manchester, UK
| | - P Foden
- Department of Biostatistics, University of Manchester, Manchester, UK
| | - P Brenchley
- Renal Research Division, Central Manchester University Hospitals NHS Trust, Manchester, UK
| | - A Wearden
- School of Psychological Sciences, University of Manchester, Manchester, UK
| | - S Mitra
- Renal Research Division, Central Manchester University Hospitals NHS Trust, Manchester, UK
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