Understanding kidney transplant patients' treatment choices: The interaction of emotion with medical and social influences on risk preferences

Young adults with kidney failure lived experiences of kidney replacement therapy decision-making

BACKGROUND

Young adults living with kidney failure make decisions to select a kidney replacement therapy choice in partnership with healthcare professionals. However, little is known about how they experience kidney replacement therapy treatment decision-making and the impact this has on their well-being.

OBJECTIVES

To explore young adults living with kidney failure experiences of treatment decision-making. The treatment decision-making investigated is about the choice of dialysis and/or kidney transplant options.

DESIGN

A qualitative interpretive hermeneutic phenomenology study.

PARTICIPANTS

Purposeful sampling was used to recruit young adults with kidney failure from social media, electronic media such as local kidney group websites and word of mouth. Semistructured interviews were conducted with (n = 18) participants aged 18-30 years.

APPROACH

Inductive analysis of the data were performed using Braun and Clarke's thematic analysis framework.

FINDINGS

The five themes generated were (1) awareness and anticipation of future kidney replacement therapy decision; (2) health information and education; (3) engaging in decision-making, support and choices; (4) implementation of kidney replacement therapy and transitioning into the new normal life and (5) the impact of decision-making and choice on well-being.

CONCLUSIONS

Decision-making significantly affected young adults' psychosocial and mental well-being. Young adults had unmet informational and decisional needs and struggled to cope due to lack of support. A four-talk model, with an implement talk phase added to the existing three-talk (team talk, option talk, decision talk) shared decision-making model, would promote a focus on the implementation of choice and support the transitioning from previous life to long-term dependence on treatment.

Negotiating treatment and managing expectations in chronic kidney disease: A qualitative study in Argentina

OBJECTIVES

To describe how patients with CKD negotiated assigned responsibilities in the management of their disease, resulting in potential relational nonadherence.

METHODS

Qualitative study performed in two healthcare facilities in Buenos Aires, Argentina, including 50 patients and 14 healthcare providers. We conducted semistructured interviews which were analysed using a frame of reference with concepts of Burden of Treatment and Cognitive Authority theories.

FINDINGS

Adherence to treatment defined "good patients". Patients needed to negotiate starting treatment, its modality and dialysis schedule, although most patients felt they did not participate in the decision process and that providers did not acknowledge implications of these decisions on their routine. Some patients skipped dialysis if concerns were not attended. Regularly, patients negotiated frequency of visits, doses, dietary restrictions and redefined relationships with their support networks, sometimes with devasting effects. As a result of overwhelming uncertainty some patients refused enrolling into a transplant program. When the frequency of complications increased, patients considered abandoning dialysis.

CONCLUSION

When patients perceived demands were excessive or conflicting, they entered into negotiations. Relationally induced nonadherence may arise when professionals do not or cannot enter into negotiations over patients' beliefs or knowledge about what is possible for them to do.

Decision-making Among Hepatitis C Virus-negative Transplant Candidates Offered Organs from Donors with HCV Infection

Background

Historically, many organs from deceased donors with hepatitis C virus (HCV) were discarded. The advent of highly curative direct-acting antiviral (DAA) therapies motivated transplant centers to conduct trials of transplanting HCV-viremic organs (nucleic acid amplification test positive) into HCV-negative recipients, followed by DAA treatment. However, the factors that influence candidates' decisions regarding acceptance of transplant with HCV-viremic organs are not well understood.

Methods

To explore patient-level perceptions, influences, and experiences that inform candidate decision-making regarding transplant with organs from HCV-viremic donors, we conducted a qualitative semistructured interview study embedded within 3 clinical trials investigating the safety and efficacy of transplanting lungs and kidneys from HCV-viremic donors into HCV-negative recipients. The study was conducted from June 2019 to March 2021.

Results

Among 44 HCV-negative patients listed for organ transplant who were approached for enrollment in the applicable clinical trial, 3 approaches to decision-making emerged: positivist, risk analyses, and instinctual response. Perceptions of risk contributed to conceptualizations of factors influencing decisions. Moreover, most participants relied on multiple decision-making approaches, either simultaneously or sequentially.

Conclusions

Understanding how different decisional models influence patients' choices regarding transplant with organs from HCV-viremic donors may promote shared decision-making among transplant patients and providers.

Pretransplant Patient Education in Solid-organ Transplant: A Narrative Review

Education for pretransplant, solid-organ recipient candidates aims to improve knowledge and understanding about the transplant process, outcomes, and potential complications to support informed, shared decision-making to reduce fears and anxieties about transplant, inform expectations, and facilitate adjustment to posttransplant life. In this review, we summarize novel pretransplant initiatives and approaches to educate solid-organ transplant recipient candidates. First, we review approaches that may be common to all solid-organ transplants, then we summarize interventions specific to kidney, liver, lung, and heart transplant. We describe evidence that emphasizes the need for multidisciplinary approaches to transplant education. We also summarize initiatives that consider online (eHealth) and mobile (mHealth) solutions. Finally, we highlight education initiatives that support racialized or otherwise marginalized communities to improve equitable access to solid-organ transplant. A considerable amount of work has been done in solid-organ transplant since the early 2000s with promising results. However, many studies on education for pretransplant recipient candidates involve relatively small samples and nonrandomized designs and focus on short-term surrogate outcomes. Overall, many of these studies have a high risk of bias. Frequently, interventions assessed are not well characterized or they are combined with administrative and data-driven initiatives into multifaceted interventions, which makes it difficult to assess the impact of the education component on outcomes. In the future, well-designed studies rigorously assessing well-defined surrogate and clinical outcomes will be needed to evaluate the impact of many promising initiatives.

Perspectives of solid organ transplant recipients on medicine-taking: Systematic review of qualitative studies

Medicine-taking among transplant recipients is a complex and ubiquitous task with significant impacts on outcomes. This study aimed to describe the perspectives and experiences of medicine-taking in adult solid organ transplant recipients. Electronic databases were searched to July 2020, and thematic synthesis was used to analyze the data. From 119 studies (n = 2901), we identified six themes: threats to identity and ambitions (impaired self-image, restricting goals and roles, loss of financial independence); navigating through uncertainty and distrust (lacking tangible/perceptible benefits, unprepared for side effects, isolation in decision-making); alleviating treatment burdens (establishing and mastering routines, counteracting side effects, preparing for the unexpected); gaining and seeking confidence (clarity with knowledge, reassurance through collective experiences, focusing on the future outlook); recalibrating to a new normal posttransplant (adjusting to ongoing dependence on medications, in both states of illness and health, unfulfilled expectations); and preserving graft survival (maintaining the ability to participate in life, avoiding rejection, enacting a social responsibility of giving back). Transplant recipients take medications to preserve graft function, but dependence on medications jeopardizes their sense of normality. Interventions supporting the adaptation to medicine-taking and addressing treatment burdens may improve patient satisfaction and capacities to take medications for improved outcomes.

Decision-making experiences of young adults with long-term conditions

BACKGROUND

Young adults with long-term conditions can struggle to accept their diagnosis and can become overwhelmed with managing their condition. Suboptimal transfer from paediatric to adult services with a resultant disengagement with the service can result in less involvement in care and decision-making. Shared decision-making can improve involvement in health decisions and increase satisfaction with treatment/therapy and care.

OBJECTIVES

An integrative literature review was conducted to explore and understand young adults' experiences of decision-making in health care.

DESIGN

An integrative literature review.

DATA SOURCES

CINAHL, EMCARE, PsycINFO, HMIC, EMBASE, Web of Science, PubMed, MEDLINE, EBSCOHOST and COCHRANE databases were searched for relevant literature published between January 1999 and January 2020.

FINDINGS

Thirteen primary research papers met the inclusion criteria. Four main themes were identified: (1) Information delivery and communication; (2) participation in decision-making; (3) social factors influencing decision-making and (4) emotional impact of decision-making.

CONCLUSIONS

Young adults with long-term conditions have specific decision-making needs which can impact their emotional health. Research with a specific focus on young adults' experiences of decision-making in health care is needed.

Understanding family dynamics in adult-to-adult living donor liver transplantation decision-making in Taiwan: Motivation, communication, and ambivalence

This study investigated how multiple family members co-construct the ethical significance of living donor liver transplantation (LDLT) and how the family structure and dynamics of donor-recipient-caregiver relationships shape the communication and decision-making process within the sociocultural context of Taiwan. We conducted in-depth interviews with 36 participants from 13 families at the Chang Gung Memorial Hospital from February to December 2019. Interviews were audio recorded, transcribed, and translated from Mandarin to English and analyzed utilizing grounded theory and thematic analysis. Our findings revealed that LDLT in Taiwan is not merely a personal choice of either donor or recipient but essentially a collaborative process of family-centered medical decision-making, intertwined with socioeconomic conditions, cultural and social norms, gender roles, and the division of labor in the household. The notion of reciprocity and indebtedness for family members is a central theme underlying the entire process of motivation, deliberation, and decision-making, thereby reinforcing the naturalness of LDLT. However, our study highlighted that donors from families with traditional gender hierarchy and power imbalance may experience psychological and social vulnerabilities. Conclusively, we suggest that healthcare professionals should be sensitive to the contextual and relational factors involved in family dynamics and provide appropriate support to the ambivalent donors.

Living in limbo while one's identity is changing: Patients' existential experiences 6 months after a kidney transplantation with a living donor

AIM

To investigate patients' existential experiences in everyday life after a kidney transplantation with a living donor.

DESIGN

A qualitative study anchored in a hermeneutic-phenomenological approach inspired by Ricoeur's theory of narrative and interpretation.

METHOD

Eleven patient interviews were conducted approximately 6 months after a kidney transplantation with a living donor. The interviews were conducted between August 2017-May 2019. Analysis and interpretation are based on Ricoeur's theory of interpretation.

RESULTS

Four themes were identified: Experiencing bodily vulnerability while getting back to life; Feeling guilt while experiencing gratitude; Living in limbo while one's identity is changing; and Facing the future with hope while having reservations.

CONCLUSION

This study reveals that patients experience multifaceted existential challenges in their everyday lives during the transition of the kidney transplantation process. Post-surgery complications for donors lead to feelings of guilt in patients; plus, they must adapt to a new existence, including a new identity. The patients feel they are in limbo, as they experience their existence as uncertain and their identity as unknown.

IMPACT

The study highlights a need for developing a rehabilitation programme to address the individual and various existential challenges faced by patients who need to undergo a kidney transplantation.

Organ utilization - the next hurdle in transplantation?

Nonutilization of organs from consented deceased donors remains a significant factor in limiting patient access to transplantation. Critical to reducing waste is a clear understanding of why organs are not used: accurate metrics are essential to identify the extent and causes of waste but use of these measures as targets or comparators between units/jurisdictions must be done with caution as focus on any one measure may result in unintended adverse consequences. Comparison between centres or countries may be misleading because of variation in definitions, patient or graft characteristics. Two of the most challenging areas to improve appropriate deceased donor organ utilization are appetite for risk and lack of validated tools to help identify an organ that will function appropriately. Currently, the implanting surgeon is widely considered to be accountable for the use of a donated organ so guidelines must be clear to allow and support sensible decisions and recognition that graft failure or inadvertent disease transmission are not necessarily attributable to poor decision-making. Accepting an organ involves balancing risk and benefit for the potential recipient. Novel technologies such as machine perfusion may allow for more robust guidance as to the functioning of the organ.

Work of being an adult patient with chronic kidney disease: a systematic review of qualitative studies

INTRODUCTION

Chronic kidney disease (CKD) requires patients and caregivers to invest in self-care and self-management of their disease. We aimed to describe the work for adult patients that follows from these investments and develop an understanding of burden of treatment (BoT).

METHODS

Systematic review of qualitative primary studies that builds on EXPERTS1 Protocol, PROSPERO registration number: CRD42014014547. We included research published in English, Spanish and Portuguese, from 2000 to present, describing experience of illness and healthcare of people with CKD and caregivers. Searches were conducted in MEDLINE, Embase, CINAHL Plus, PsycINFO, Scopus, Scientific Electronic Library Online and Red de Revistas Científicas de América Latina y el Caribe, España y Portugal. Content was analysed with theoretical framework using middle-range theories.

RESULTS

Searches resulted in 260 studies from 30 countries (5115 patients and 1071 carers). Socioeconomic status was central to the experience of CKD, especially in its advanced stages when renal replacement treatment is necessary. Unfunded healthcare was fragmented and of indeterminate duration, with patients often depending on emergency care. Treatment could lead to unemployment, and in turn, to uninsurance or underinsurance. Patients feared catastrophic events because of diminished financial capacity and made strenuous efforts to prevent them. Transportation to and from haemodialysis centre, with variable availability and cost, was a common problem, aggravated for patients in non-urban areas, or with young children, and low resources. Additional work for those uninsured or underinsured included fund-raising. Transplanted patients needed to manage finances and responsibilities in an uncertain context. Information on the disease, treatment options and immunosuppressants side effects was a widespread problem.

CONCLUSIONS

Being a person with end-stage kidney disease always implied high burden, time-consuming, invasive and exhausting tasks, impacting on all aspects of patients' and caregivers' lives. Further research on BoT could inform healthcare professionals and policy makers about factors that shape patients' trajectories and contribute towards a better illness experience for those living with CKD.

PROSPERO REGISTRATION NUMBER

CRD42014014547.

Treatment decision-making in chronic diseases: What are the family members' roles, needs and attitudes? A systematic review

OBJECTIVE

This systematic review aims to examine the roles of family members (FMs) in treatment decision-making for adult patients without cognitive or psychiatric disorders affecting their ability to participate in decision-making.

METHODOLOGY

A comprehensive, systematic search of the Cochrane Library, PsycINFO, PubMed and ScienceDirect databases, with relevant keywords, was conducted. Two authors evaluated the eligibility of the studies independently, then cross-checked for accuracy. The quality of included studies were assessed using standardized criteria.

RESULTS

Out of the 12.137 studies identified, 40 were included. Results highlighted the different roles and influences FMs have in the decision-making process. Moreover, several factors ranging from personal to cultural and family-related factors influence their level of involvement. Regardless of the illness, some similarities in family influence exist (e.g., social support). However, the type of family involvement varies according to the illness, the treatment choice and the patients' culture.

CONCLUSION

FMs have an important role in the decision-making process. In fact, the final decision is often made by the patients after consulting their families. FMs can support both patients and medical teams, and thus facilitate the process.

PRACTICE IMPLICATIONS

Physicians should include FMs in treatment decision-making when the patients and their FMs wish to be included.