Nephrologists' emotional burden regarding decision-making about dialysis initiation in older adults: a qualitative study

Nephrologists' perspectives and experiences with hospice among older adults with end-stage kidney disease

BACKGROUND

Hospice care leads to improved patient and family outcomes. Hospice use among older adults with end-stage kidney disease (ESKD) is markedly lower than among older adults with other serious illnesses, and the majority of those with ESKD who use hospice enroll in the last days of life. Here, our aim was to explore barriers to timely receipt of high-quality hospice care for older adults with ESKD.

METHODS

Utilizing a qualitative study design, we conducted a secondary analysis focused on hospice, a theme that we identified in our larger overarching study that involved semi-structured interviews with 20 nephrologists in the United States focused on treatment decision-making in older adults with advanced chronic kidney disease. We analyzed the interview transcripts using emergent thematic analysis to develop an understanding of barriers to high-quality hospice.

RESULTS

With a couple notable exceptions, nephrologists voiced general support for the concept of hospice, but few recalled patients of theirs who had received hospice. Nephrologists' interviews revealed two interrelated contributors to the lack of timely access to high-quality hospice care for seriously ill older adults with ESKD: (1) nephrologists view dialysis and hospice as mutually exclusive models of care; (2) nephrologists feel unsure who should manage hospice care for patients with ESKD. The first contributor was rooted in nephrologists' narrow vision of when to consider hospice (informed, in part, by policy barriers) and, in a couple of cases, strong discomfort with hospice. The second stemmed from nephrologists' belief that neither they nor hospice are adequately prepared to provide hospice care for ESKD.

CONCLUSIONS

Our findings suggest that, in addition to Medicare policy change, nephrologists need to receive more training in primary palliative care skills including in indications for hospice, initiating conversations about hospice with patients, and collaborating with hospice clinicians to care for these vulnerable patients.

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

OBJECTIVE

To describe and analyse the perspectives and communication practices of kidney clinicians and older patients (aged 60 +) during collaborative education and decision-making about dialysis.

METHODS

This qualitative study drew on pluralistic data sources and analytical approaches investigating elicited semi-structured interviews (n = 31) with doctors (n = 8), nurses (n = 8) and patients (n = 15), combined with ethnographic observations, written artefacts and audio-recorded naturally-occurring interactions (n = 23, education sessions n = 4; consultations n = 19) in a tertiary Australian kidney outpatient clinic. Data were analysed for themes and linguistic discourse features.

RESULTS

Five themes were identified across all data sources: 1) lost opportunity in education; 2) persistent disease knowledge gaps; 3) putting up with dialysis; 4) perceived and real involvement in decision-making and 5) complex role of family as decision-making brokers.

CONCLUSION

As the first study to complement interviews with evidence from naturally-occurring kidney interactions, this study balances the perspectives of how older patients and their clinicians view chronic kidney disease education, with how decision-making about dialysis is reflected in practice.

PRACTICE IMPLICATIONS

The study provides suggestions for contextualized, multi-perspectives formal and informal training for improving decision-making about dialysis, spanning from indications to boost communication efficiency, to reducing unexplained jargon, incorporating patient navigators and exploring different dialysis modalities.

Kidney supportive care for advanced chronic and end-stage kidney disease: a retrospective cohort study

BACKGROUND

Kidney supportive care is an interdisciplinary model of person-centred medicine, suitable for patients with advanced Chronic Kidney Disease (CKD) and with End-Stage Kidney Disease (ESKD). There is little information on routine care, and palliative care remains poorly integrated into standard nephrology care. The aim of this study was to describe our experience in integrating a palliative care approach into the nephrology care of advanced chronic and end-stage kidney disease.

METHODS

A retrospective cohort study was conducted from 1 June, 2017 until 31 December, 2020 on 67 advanced CKD and ESKD patients admitted to a palliative care service.

RESULTS

The patients' median age was 83.6 years, 62.7% were male, 16.4% had CKD stage 4 and 83.6% stage 5. Almost half (47.8%) of the patients were on kidney replacement therapy, and 52.2% were on conservative therapy. The majority (77.6%) received home-based palliative care, 17.9% hospice care and 4.5% day-hospice care. The median number of nephrologists' visits per patient was 3.5. Access to palliative care specialists was set at 100% and the median number of palliative clinicians' visits was 8. Eighty-five percent of patients did not require hospitalisation and 94% did not access to the emergency room; 86.2% of the patients died in hospice or at home.

CONCLUSIONS

This study reports on the first steps taken to change practice in nephrology, by applying the Italian guideline for an integrated pathway of palliative care in nephrology. Nephrologists' and the palliative care team created a multi- and inter-disciplinary team, sharing their professional skills to support patients in hospice or at home.

Factors that influence the selection of conservative management for end-stage renal disease - a systematic review

Background

Most patients with end-stage renal disease (ESRD) are managed with dialysis and less commonly kidney transplantation. However, not all are suitable for or desire either of these renal replacement therapies. Conservative management (CM) is an option. However, the selection of CM is often not easy for patients and clinicians. The aim of this systematic review is to identify the key factors that influence the selection of CM for ESRD.

Methods

Medline, Embase, PsychINFO, and CINAHL Plus were systematically searched from inception to 10 September 2021. Titles/abstracts and full texts were independently screened by two reviewers. Reference lists of included articles were searched. An update search via PubMed was conducted on 10 August 2023. A narrative synthesis of review findings was conducted.

Results

At the end of the screening process, 15 qualitative and 8 survey articles were selected. Reference checking yielded no additional relevant studies. Main themes were: (i) Patient-specific factors; (ii) Clinician-specific factors; (iii) Organisational factors; and (iv) National and international factors. Patient-specific factors were awareness and perceptions of CM and dialysis, beliefs about survival, preferred treatment outcomes and influence of family/caregivers and clinicians. Clinician-specific factors included perceptions of CM as 'non-intervention', perceptions of clinician role in the decision-making process, and confidence and ability to initiate sensitive treatment discussions. Relationships with and involvement of other healthcare professionals, time constraints, and limited clinical guidance were also important factors.

Conclusions

An improvement in the provision of education regarding CM for patients, caregivers, and clinicians is essential. Robust studies are required to generate crucial evidence for the development of stronger recommendations and guidance for clinicians.

Psychological Determinants of Physician Variation in End-of-Life Treatment Intensity: A Systematic Review and Meta-Synthesis

BACKGROUND

Physicians treating similar patients in similar care-delivery contexts vary in the intensity of life-extending care provided to their patients at the end-of-life. Physician psychological propensities are an important potential determinant of this variability, but the pertinent literature has yet to be synthesized.

OBJECTIVE

Conduct a review of qualitative studies to explicate whether and how psychological propensities could result in some physicians providing more intensive treatment than others.

METHODS

Systematic searches were conducted in five major electronic databases-MEDLINE ALL (Ovid), Embase (Elsevier), CINAHL (EBSCO), PsycINFO (Ovid), and Cochrane CENTRAL (Wiley)-to identify eligible studies (earliest available date to August 2021). Eligibility criteria included examination of a physician psychological factor as relating to end-of-life care intensity in advanced life-limiting illness. Findings from individual studies were pooled and synthesized using thematic analysis, which identified common, prevalent themes across findings.

RESULTS

The search identified 5623 references, of which 28 were included in the final synthesis. Seven psychological propensities were identified as influencing physician judgments regarding whether and when to withhold or de-escalate life-extending treatments resulting in higher treatment intensity: (1) professional identity as someone who extends lifespan, (2) mortality aversion, (3) communication avoidance, (4) conflict avoidance, (5) personal values favoring life extension, (6) decisional avoidance, and (7) over-optimism.

CONCLUSIONS

Psychological propensities could influence physician judgments regarding whether and when to de-escalate life-extending treatments. Future work should examine how individual and environmental factors combine to create such propensities, and how addressing these propensities could reduce physician-attributed variation in end-of-life care intensity.

Knowledge, attitude, and practice of nephrologists on the decision for renal replacement therapy

BACKGROUND

This study aimed to investigate the Knowledge, Attitude, and Practice (KAP) of nephrologists on the decision of renal replacement therapy (RRT), including peritoneal dialysis, hemodialysis, and kidney transplantation.

METHODS

This multicenter cross-sectional study was conducted on qualified nephrologists who volunteered to participate between July and August 2022 by using a self-administered questionnaire.

RESULTS

Among 327 nephrologists, the total knowledge, attitude, and practice scores were 12.03 ± 2.11/16, 58.39 ± 6.62/75, and 27.15 ± 2.74/30, respectively. Multivariate logistic regression analysis showed that the attitude score (peritoneal dialysis: OR = 1.19, 95%CI: 1.13-1.25, P < 0.001; hemodialysis: OR = 1.14, 95%CI: 1.09-1.19, P < 0.001; kidney transplantation: OR = 1.12, 95%CI: 1.07-1.16, P < 0.001), 41-50 years of age (peritoneal dialysis: OR = 0.45, 95%CI: 0.21-0,98, P = 0.045; hemodialysis: OR = 0.27, 95%CI: 0.12-0.60, P = 0.001; kidney transplantation: OR = 0.45, 95%CI:0.20-0.97, P = 0.042), and > 50 years of age (peritoneal dialysis: OR = 0.27, 95%CI: 0.08-0.84, P = 0.024; hemodialysis: OR = 0.45, 95%CI: 0.20-0.97, P = 0.042; kidney transplantation: OR = 0.24, 95%CI: 0.08-0.77, P = 0.016) were independently associated with the consideration score of peritoneal dialysis, hemodialysis, and kidney transplantation.

CONCLUSION

Better attitudes may lead to more consideration by nephrologists when choosing between peritoneal dialysis, hemodialysis, and kidney transplantation and relatively less consideration by senior physicians when making decisions; in addition, having good knowledge and good attitudes may lead to better practice.

Dialysis Access Considerations in Kidney Palliative Care

In this review, we discuss common challenges at the interface between dialysis access planning, prognostication, and patient-centered decision making. Particularly for patients whose survival benefit from dialysis is attenuated by advanced age or other serious illness, knowing the potential complications and anticipated frequency of access procedures is essential for patients and families to be able to conceptualize what life on dialysis will look like. Although starting dialysis with a functioning graft or fistula is associated with reduced infection rates, mortality, hospitalizations, and cost compared with a central venous catheter, these benefits must be weighed against the chance that early access placement in an elderly or seriously ill patient is an unnecessary surgery because the chronic kidney disease never progresses, the patient dies before developing an indication to start dialysis, or, the patient prefers conservative kidney management over dialysis. Kidney palliative care is a growing subspecialty of nephrology focused on helping seriously ill patients navigate complex medical decisions, and may be useful for intensive goals-of-care discussions about treatment and access options for patients with limited anticipated survival because of age or other serious illness.

Challenges to Shared Decision Making About Treatment of Advanced CKD: A Qualitative Study of Patients and Clinicians

RATIONALE AND OBJECTIVE

Greater understanding of the challenges to shared decision-making about treatment of advanced CKD is needed to support implementation of shared decision-making in clinical practice.

STUDY DESIGN

Qualitative study.

SETTING AND PARTICIPANTS

Patients aged ≥65 years with advanced CKD and their clinicians recruited from 3 medical centers participated in semi-structured interviews. In-depth review of patients' electronic medical records was also performed.

ANALYTICAL APPROACH

Interview transcripts and medical record notes were analyzed using inductive thematic analysis.

RESULTS

Twenty-nine patients (age 73±6 years, 66% male, 59% Caucasian) and 10 of their clinicians (age 52±12 years, 30% male, 70% Caucasian) participated in interviews. Four themes emerged from qualitative analysis: 1) Competing priorities - patients and their clinicians tended to differ on when to prioritize CKD and dialysis planning above other personal or medical problems; 2) Focusing on present or future -patients were more focused on living well now while clinicians were more focused on preparing for dialysis and future adverse events; 3) Standardized versus individualized approach to CKD - although clinicians tried to personalize care recommendations to their patients, patients perceived their clinicians as taking a monolithic approach to CKD that was predicated on clinical practice guidelines and medical literature rather than patients' lived experiences with CKD and personal values and goals; and 4) Power dynamics - while patients described cautiously navigating a power differential in their therapeutic relationship with their clinicians, clinicians seemed less attuned to these power dynamics.

LIMITATIONS

Thematic saturation was based on patient interviews. Themes presented might incompletely reflect clinicians' perspectives.

CONCLUSIONS

Efforts to improve shared decision-making for treatment of advanced CKD will likely need to explicitly address differences in approaches to decision-making about treatment of advanced CKD between patients and their clinicians and perceived power imbalances in the therapeutic relationship.

NephroTalk Multimodal Conservative Care Curriculum for Nephrology Fellows

Conservative care, a comprehensive treatment path for advanced kidney disease most suitable for individuals unlikely to benefit from dialysis, is underutilized in the United States. One reason is an absence of robust education about this approach and how to discuss it with potential candidates. To address this need, we developed a multimodal conservative care curriculum for nephrology fellows. This curriculum consists of four online modules that address essential concepts and communication skills related to conservative care. It is followed by an in-person, interactive, "flipped classroom" session facilitated by designated nephrology educators at participating Accreditation Council for Graduate Medical Education nephrology training programs. Curriculum effect was assessed using surveys completed by participating fellows immediately before and following the curriculum and for participating nephrology educators following flipped classroom teaching; 148 nephrology trainees from 19 programs participated, with 108 completing both pre- and postcurriculum surveys. Mean self-reported preparedness (measured on a five-point Likert scale) increased significantly for all ten concepts taught in the curriculum. The mean correct score on eight knowledge questions increased from 69% to 82% following the curriculum (P<0.001). Fellows rated the curriculum highly and reported that they plan to practice skills learned. For the 19 nephrology program educators, the mean perceived preparedness to teach all curriculum domains increased after, compared with before, facilitating the flipped classroom, reaching significance for seven of the ten concepts measured. Data suggest that fellows' participation in a multimodal curriculum increased knowledge and preparation for fundamental conservative care concepts and communication skills. Fellows rated the curriculum highly. Educator participation appears to have increased preparedness for teaching the curriculum concepts, making it likely that future education in conservative care will become more widespread. Herein, we describe the curriculum content, which we have made publicly available in order to encourage broader implementation, and its effect on participating fellows and the nephrology educators who facilitated it.

Serious Illness Conversations in advanced kidney disease: a mixed-methods implementation study

OBJECTIVE

Advanced kidney disease is associated with a high risk of morbidity and mortality. Consequently, invasive treatments such as dialysis may not yield survival benefits. Advance care planning has been encouraged. However, whether such discussions are acceptable when done earlier, before end-stage kidney treatment decision-making occurs, is unclear. This pilot study aimed to explore whether use of the Serious Illness Conversation Guide to aid early advance care planning is acceptable, and to evaluate the information gained from these conversations.

METHODS

Patients with advanced kidney disease (stage 3B and above) and high mortality risk at 2 years were enrolled in this mixed-methods study from an academic nephrology clinic. Semi-structured interviews were conducted using the adapted Serious Illness Conversation Guide. Thematic analysis was used to assess patients' perceptions of the conversation. Participants completed a questionnaire assessing conversation acceptability.

RESULTS

Twenty-six patients participated, 50% were female. Participants felt that the conversation guide helped them reflect on their prognosis, goals of care and treatment preferences. Most did not feel that the conversation provoked anxiety (23/26, 88%) nor that it decreased hopefulness (24/26, 92%). Some challenges were elicited; patients expressed cognitive dissonance with the kidney disease severity due to lack of symptoms; had difficulty conceptualising their goals of care; and vocalised fear of personal failure without attempting dialysis.

CONCLUSIONS

Patients in this pilot study found the adapted Serious Illness Conversation Guide acceptable. This guide may be used with patients early in the course of advanced kidney disease to gather information for future advanced care planning.

Barriers to Conservative Management Conversations: Perceptions of Nephrologists and Fellows-in-Training

Background: Not all treatments are appropriate for all individuals with kidney failure (KF). Studies suggest that conversations surrounding end-of-life decisions occur too late or not at all. Objectives: The aim of this research was to identify perceived barriers to such discussions among nephrologists and nephrology fellows to determine if barriers differ by experience level. Design: Phase I consisted of semistructured telephone interviews with nephrologists and fellows. Phase II included focus groups with nominal group technique in which providers ranked barriers to discussions about not initiating/withholding dialysis (NIWD) or discontinuing dialysis (DD). Setting/Subjects: U.S. community-based nephrologists and nephrology fellows. Results: Seven interviews were conducted with each group (n = 14) in phase I. Many barriers cited were similar among providers, however, differences were related to fellows' position as trainees citing the "reaction of their attending/supervising physician or other providers" as a barrier to NIWD and "lacking their attending physician's support" as a barrier to DD. Six focus groups were conducted, nephrologists (n = 22) and fellows (n = 18), in phase II. The highest ranked barrier to NIWD for nephrologists was "discordant opinions among patient and family"; fellows ranked "time to hold conversation" highest. Nephrologists' highest barrier to DD was the "finality of the decision (death)"; fellows ranked the "inertia of the clinical encounter" highest. Conclusions: Capturing the perspectives of nephrologists and fellows concerning the barriers to conservative management of patients with KF may inform the development of targeted education/training interventions by experience level focused on communication skills, conflict resolution, and negotiation.

Fragmentation of care as a barrier to optimal ESKD management

Caring for patients with end-stage kidney disease (ESKD) in the United States is challenging, due in part to the complex epidemiology of the disease's progression as well as the ways in which care is delivered. As CKD progresses toward ESKD, the number of comorbidities increases and care involves multiple healthcare providers from multiple subspecialties. This occurs in the context of a fragmented US healthcare delivery system that is traditionally siloed by provider specialty, organization, as well as systems of payment and administration. This article describes the role of care fragmentation in the delivery of optimal ESKD care and identifies research gaps in the evidence across the continuum of care. We then consider the impact of care fragmentation on ESKD care from the patient and health system perspectives and explore opportunities for system-level interventions aimed at improving care for patients with ESKD.