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Study finds barriers to discussion of conservative management for older patients with CKD
Conservative management is not routinely discussed as an alternative to dialysis among patients older than 75 years, according to results of a recently published study that identified five themes related to nephrologists’ discussion of conservative treatment with patients.
Researchers conducted 35 semi-structured interviews with nephrologists from 18 practices. Of this group, 37% of nephrologists said they routinely discussed conservative management as an alternative to dialysis. Researchers also found 66% of those interviewed said they had 10 or more years of nephrology experience and while awareness of conservative management as a legitimate alternative to dialysis had increased, discussion remained infrequent.
Researchers found five themes and related subthemes when deciding whether to discuss conservative management with older patients:
Struggling to define nephrologists’ roles – Subthemes included nephrologists determining treatment and deciding their role vs. patient autonomy, viewing instilling hope and improving patient symptoms.
Circumventing end-of-life conversations – focused on active treatments, while obscuring the terminal nature of chronic kidney disease. Subthemes included contending with uncertain prognosis, fearing emotional backlash, fear of jeopardizing their longstanding relationships and tailoring information to specific populations.
Confronting institutional barriers –reinforced physician-level barriers, dissuading many from discussing conservative management. Subthemes included coping with time constraints, attempting care coordination, incentivizing dialysis and discomfort with varied conservative management approaches.
Conservative management as “no care” – participants perceived conservative management as not providing care. Many equated conservative management with certain death.
Experiencing moral distress as catalyst for conservative management – occurred when clinicians were aware of a moral problem and perceived a responsibility to act, yet because of institutional constraints, could not act in a way consistent with their moral judgments.
Moral distress emerged as a leading factor in not discussing conservative management with patients. It distinguished the 37% from others, catalyzing them and increasing their vigilance in discussing conservative management routinely. The futility of dialysis in older patients also had a role in discussion of conservative management. One individual told researchers, “I’ve noticed with several of my older colleagues that we have far less trouble in saying, ‘This is enough ... there’s no quality of life here, there’s no chance of any meaningful recovery, why are we flogging this poor person?’ Whereas my younger colleagues are fighting to the bitter end.”
Disclosure s : The authors reported no relevant financial disclosures.