Researchers have revealed that care discussions with older patients with chronic kidney disease (CKD) do not routinely include the topic of conservative management. The study findings were published in the American Journal of Kidney Diseases.
Although dialysis may not provide a large survival benefit for older patients with kidney failure, few are informed about conservative management. Barriers and facilitators to discussions about conservative management and nephrologists’ decisions to present the option of conservative management may vary within the nephrology provider community.
The national sample of US nephrologists sampled based on sex, years in practice, practice type, and region. Qualitative semistructured interviews continued until thematic saturation. Thematic and narrative analysis of recorded and transcribed interviews.
Among 35 semistructured interviews with nephrologists from 18 practices, 37% described routinely discussing conservative management (“early adopters”). 5 themes and related subthemes reflected issues that influence nephrologists’ decisions to discuss conservative management and their approaches to these discussions.
Struggling to define nephrologists’ roles (determining treatment, instilling hope, and improving patient symptoms), circumventing end-of-life conversations, confronting institutional barriers (time constraints, care coordination, incentives for dialysis, and discomfort with varied conservative management approaches), conservative management as no care, and moral distress.
Nephrologists’ approaches to conservative management discussions were shaped by perceptions of their roles and by a common view of conservative management as no care. Their willingness to pursue conservative management was influenced by provider- and institutional-level barriers and experiences with older patients who regretted or had been harmed by dialysis (moral distress).
Early adopters routinely discussed conservative management as a way of relieving moral distress, whereas others who were more selective in discussing conservative management experienced greater distress. The limitation of the study was participants’ views are likely most transferable to large academic medical centres, due to oversampling of academic clinicians.
Researchers found that care discussions with older patients with CKD do not routinely include the topic of conservative management. Discussion ranged from presenting conservative management as a comparable alternative to dialysis therapy to omitting it entirely. Nephrologists’ approach to discussions about conservative management was largely shaped by perceptions of their role and by a common view of conservative management as no care. The findings clarify how moral distress serves as a catalyst for the discussion of conservative management and highlight points of intervention and mechanisms potentially underlying low conservative management use in the United States.