Patients prefer shared decision -making for kidney failure, but discussions infrequent
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Although most patients with chronic kidney disease preferred making decisions on kidney failure treatments with their care teams, a study revealed shared decision-making occurred infrequently.
Further, for patients who did engage in shared decision-making conversations, researchers found key topics related to treatment — such as long-term financial impact — were not discussed.
Shared decision-making
According to Tyler M. Barrett, MA, of Duke University School of Medicine, and colleagues, it is important to evaluate shared decision-making at earlier stages of kidney disease to improve how “kidney care teams prepare their patients for kidney failure.”
For the cross-sectional study, researchers considered the frequency and quality of kidney replacement therapy discussions among 447 patients receiving nephrology care at CKD clinics in rural Pennsylvania (mean age was 72 years; mean eGFR was 33 mL/min/1.73 m2; 96% were white and 67% had a high school education).
“Given that high-quality shared decision-making discussions should also be informed, we assessed participants’ preferences for and experiences of shared and informed decision-making (referred to throughout as SDM),” Barrett and colleagues wrote. “In doing so, we asked participants a range of questions across domains important to high quality SDM discussions, including whether discussions occurred, participants’ perceived completeness of those discussions, whether key topics were discussed, and participants’ satisfaction with discussions.
While other tools capture the decision-making process in specific clinical encounters, our objective was to gain insight into participants’ decision-making preferences and experiences throughout their history of nephrology care.”
Findings revealed that while 15% of patients preferred to make treatment decisions themselves, 72% expressed a preference for a shared approach to kidney treatment decision-making (9% of participants preferred their doctor make treatment decisions for them).
Despite the preference for shared decision-making, 35% of patients had discussed dialysis or transplant with their kidney team. Those with a high risk of kidney failure within 2 years (odds ratio = 3.24), longer-term nephrology care (OR of 1.12 per 1 additional year) and more nephrology visits in the previous 2 years (OR of 1.34 per one additional visit) were more likely to have discussed these treatment options.
Conversations on treatment options, impact
When shared decision-making did occur, most patients said they were satisfied with the conversations, though less than half reported a comprehensive discussion of available options (37% discussed conservative management; 30% discussed in-center hemodialysis; 24% discussed transplant; 19% discussed home hemodialysis; and 15% discussed peritoneal dialysis).
Regarding conversations on treatment impact among patients who had discussed dialysis or transplant options, 14% reported having had a “complete” discussion encompassing the following five topics: quality of life on a day-to-day basis; length of life; need for support from family or friends; family’s well-being; and finances.
“Although most participants in our study preferred SDM, our results do not indicate that preference for SDM is associated with the actual occurrence of discussions,” Barrett and colleagues concluded of the findings. “Prior studies also suggest that patients generally prefer SDM in other therapeutic areas. Yet our findings suggest that patients may not initiate SDM discussions simply because it is their preference. Rather, these patients may be waiting for their providers to engage them in such discussions, and kidney care teams should be aware that patients may not actively pursue their preferred decision-making style. Decision aids developed for enhancing patient-provider communication in kidney care may be useful tools to help providers initiate SDM discussions.”
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