VIDEO: Shared decision-making between patient, provider remains important in CKD care

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Shared decision-making really is true partnership where we share our values in the context of the existing standard of care and the existing best standard of care. So I see it as my job as a physician to be informed of what is the best available therapy for my patient and to inform the patient of that in best way that I can, and sometimes that needs more than one encounter, it needs several encounters to have that communication.

But then I expect the patient to share with me like, what are their concerns? What are their values? And how this potentially could and could not work with their values and their lifestyle and their concerns. That helps us have an ongoing communication and a therapeutic relationship where I don't feel like my recommendation is necessarily being ignored, but rather that I understand where my patient is coming from.

And I guess the best example for that for me has been the use of tolvaptan (Samsca, Otsuka Pharmaceutical Co.), I see a lot of patients with ADPKD, and although I may tell them that yes, this is my assessment of your prognosis and this is why I would recommend tolvaptan, I have to hear from them about what their thoughts on a lifelong medication that will change their lifestyle is.

That's an ongoing conversation, and some patients will attempt something and not be able to be successful on it. And I have to have that understanding of how it's fitting with their lifestyle and their values to continue with a therapeutic relationship with them. When we're talking about shared decision-making, often, it's applied to dialysis, I think, and end stage kidney disease care. Actually, I tend to be a little bit more directive there, rather than having a completely shared decision-making there because patients don't really want to talk about it. They don't wanna face a completely life-changing treatment.

And I know you might be surprised, but I tend to tell them that this is what I would recommend for you, because I know you, because I've known you, I don't think dialysis would be a good option for you for X, Y reasons. And I outright tell them this. There are places where I am much more direct in my recommendation, whereas I think I find more room for partnership in medications, because those are things that a patient has to comply with and can affect their day-to-day life. And that's where I have more of a relationship with them about, these are the potential side effects, what stands out to you for your concern? But actually, it's less formal than that, because we get to know each other during the encounter and subsequent encounters a lot more.

I know a lot about their life, and I know, you know, are they a young parent or are they an elderly person who like, you know, tooling around the house gardening most of the time? How is this gonna fit with them? It's just personal connection and human connection that you already know and can anticipate. But true partnership isn't accepting something like, so if you think that this is something that you recommend, but the patient cannot accept it for X and Y, Z reason, the partnership comes in understanding why and still maintaining a therapeutic relationship in that context. I don't do it in a very formal way.

I mean, it's hard to sort of ask that, you know? What are your values? I sometimes like to, one of my attendings taught me this phrase when I was training, which is, how do you spend your time? What do you do with your day? So I definitely incorporate that when I first meet that person, so I get to learn who they are. I also share my values, like, I tell them about what I'm doing and when I'm going somewhere away for a while, what am I doing there, or what are my research interests, or what is my family life like? Many of my patients know all of these details about me. So it's more of a bilateral exchange and more natural.

And then when it comes down to making a decision then, both of us are able to understand each other a little better. And I always come to it from the perspective of, I want to offer you the best available thing there is. It's up to you, and I understand, like, help me understand when you don't want to accept this therapy or don't want to attempt this therapy. That's how I approach it.