Conflict when making decisions about dialysis modality

Decision Self-Efficacy and Decisional Conflict on Reintubation among Surrogates of Ventilated Patients Undergoing Planned Extubation

PURPOSE

Although the medical decision-making process can be overwhelming for some surrogates, there is a lack of understanding regarding their experiences. The objectives of this study were to examine the decision self-efficacy and decisional conflict experienced by surrogates in intensive care units (ICUs) when faced with the decision of whether to reintubate patients with respiratory failure after a planned extubation. In addition, predictors and mediators influencing these decision-making processes were identified.

METHODS

This study utilized a cross-sectional design to investigate the decision-making processes of 174 surrogates who were faced with the decision of whether to reintubate patients with respiratory failure after a planned extubation in the internal ICU of a medical center between August 2021 and February 2022. Structured questionnaires were administered to collect data on the surrogates' background information, decision self-efficacy, decisional conflict, and positive and negative affect. The patients' background information was also collected. Univariate and multivariate analyses were performed to model the data.

RESULTS

The mean decision self-efficacy score of the surrogates was 82.41 points, and 20.7% surrogates had decisional conflict scores exceeding 37.5 points, suggesting that they faced challenges in the decision-making process. Surrogates' employment status and negative affect significantly predicted their decision self-efficacy. In addition, patients' activities of daily living prior to hospitalization and the decision self-efficacy of the surrogate significantly predicted surrogate decisional conflict. The impact of surrogates' negative affect on decisional conflict was fully mediated by decision self-efficacy.

CONCLUSIONS

Surrogate decision self-efficacy mediates the relationship between negative affect and decisional conflict. Providing clinical care interventions that focus on enhancing surrogate self-efficacy and reducing negative affect can help alleviate decisional conflict in this population.

Shared Decision Making Among Older Adults With Advanced CKD

RATIONALE & OBJECTIVE

Older adults with advanced chronic kidney disease (CKD) face difficult decisions about dialysis initiation. Although shared decision making (SDM) can help align patient preferences and values with treatment options, the extent to which older patients with CKD experience SDM remains unknown.

STUDY DESIGN

A cross-sectional analysis of patient surveys examining decisional readiness, treatment options education, care partner support, and SDM.

SETTING & PARTICIPANTS

Adults aged 70 years or older from Boston, Chicago, San Diego, or Portland (Maine) with nondialysis advanced CKD.

PREDICTORS

Decisional readiness factors, treatment options education, and care partner support.

OUTCOMES

Primary: SDM measured by the 9-item Shared Decision Making Questionnaire (SDM-Q-9) instrument, with higher scores reflecting greater SDM. Exploratory: Factors associated with SDM.

ANALYTICAL APPROACH

We used multivariable linear regression models to examine the associations between SDM and predictors, controlling for demographic and health factors.

RESULTS

Among 350 participants, mean age was 78 ± 6 years, 58% were male, 13% identified as Black, and 48% had diabetes. Mean SDM-Q-9 score was 52 ± 28. SDM item agreement ranged from 41% of participants agreeing that "my doctor and I selected a treatment option together" to 73% agreeing that "my doctor told me that there are different options for treating my medical condition." In multivariable analysis adjusted for demographic characteristics, lower estimated glomerular filtration rate, and diabetes, being "well informed" and "very well informed" about kidney treatment options, having higher decisional certainty, and attendance at a kidney treatment options class were independently associated with higher SDM-Q-9 scores.

LIMITATIONS

The cross-sectional study design limits the ability to make temporal associations between SDM and the predictors.

CONCLUSIONS

Many older patients with CKD do not experience SDM when making dialysis decisions, emphasizing the need for greater access to and delivery of education for individuals with advanced CKD.

Decisional Conflict About Kidney Failure Treatment Modalities Among Adults With Advanced CKD

Rationale & Objective

Choosing from multiple kidney failure treatment modalities can create decisional conflict, but little is known about this experience before decision implementation. We explored decisional conflict about treatment for kidney failure and its associated patient characteristics in the context of advanced chronic kidney disease (CKD).

Study Design

Cross-sectional study.

Setting & Participants

Adults (N = 427) who had advanced CKD, received nephrology care in Pennsylvania-based clinics, and had no history of dialysis or transplantation.

Predictors

Participants' sociodemographic, physical health, nephrology care/knowledge, and psychosocial characteristics.

Outcomes

Participants' results on the Sure of myself; Understand information; Risk-benefit ratio; Encouragement (SURE) screening test for decisional conflict (no decisional conflict vs decisional conflict).

Analytical Approach

We used multivariable logistic regression to quantify associations between aforementioned participant characteristics and decisional conflict. We repeated analyses among a subgroup of participants at highest risk of kidney failure within 2 years.

Results

Most (76%) participants reported treatment-related decisional conflict. Participant characteristics associated with lower odds of decisional conflict included complete satisfaction with patient-kidney team treatment discussions (OR, 0.16; 95% CI, 0.03-0.88; P = 0.04), attendance of treatment education classes (OR, 0.38; 95% CI, 0.16-0.90; P = 0.03), and greater treatment-related decision self-efficacy (OR, 0.97; 95% CI, 0.94-0.99; P < 0.01). Sensitivity analyses showed a similarly high prevalence of decisional conflict (73%) and again demonstrated associations of class attendance (OR, 0.26; 95% CI, 0.07-0.96; P = 0.04) and decision self-efficacy (OR, 0.95; 95% CI, 0.91-0.99; P = 0.03) with decisional conflict.

Limitations

Single-health system study.

Conclusions

Decisional conflict was highly prevalent regardless of CKD progression risk. Findings suggest efforts to reduce decisional conflict should focus on minimizing the mismatch between clinical practice guidelines and patient-reported engagement in treatment preparation, facilitating patient-kidney team treatment discussions, and developing treatment education programs and decision support interventions that incorporate decision self-efficacy-enhancing strategies.

Disparities in dialysis modality decision-making using a social-ecological lens: a qualitative approach

BACKGROUND

Patients with end-stage kidney disease (ESKD) may choose to undergo dialysis in-center or at home, but uptake of home dialysis in the US has been minimal despite its benefits over in-center dialysis. Factors that may have led patients to select home dialysis over in-center dialysis are poorly understood in the literature, and interventions to improve selection of home dialysis have focused on patient knowledge and shared decision-making processes between patients and providers. The purpose of this study was to explore micro- and macro-level factors surrounding dialysis modality decision-making among patients undergoing in-center and home dialysis, and explore what leads patients to select home dialysis over in-center dialysis.

METHODS

Semi-structured qualitative interviews were conducted in a dialysis clinic at a large Midwestern research hospital, from September 2019 to December 2020. Participants were 18 years or older, undergoing dialysis for ESKD, and had the cognitive ability to provide consent. Surveys assessing demographic and clinical information were administered to participants following their interviews.

RESULTS

Forty patients completed interviews and surveys (20 [50%] in-center dialysis, 17 [43%] female, mean [SD] age, 59 [15.99] years). Qualitative findings suggested that healthcare access and engagement before entering nephrology care, after entering nephrology care, and following dialysis initiation influenced patients' awareness regarding their kidney disease status, progression toward ESKD, and dialysis options. Potential modifiers of these outcomes include race, ethnicity, and language barriers. Most participants adopted a passive-approach during decision-making. Finally, fatigue, concerns regarding one's dialyzing schedule, and problems with fistula/catheter access sites contributed to overall satisfaction with one's dialysis modality.

CONCLUSIONS

Findings point to broader factors affecting dialysis selection, including healthcare access and racial/ethnic inequities. Providing dialysis information before entering nephrology and after dialysis initiation may improve patient agency in decision-making. Additional resources should be prioritized for patients of underrepresented backgrounds. Dialysis decision-making may be appropriately modeled under the social-ecological framework to inform future interventions.

The experience of urgent dialysis patients with end-stage renal disease: A qualitative study

Purpose

Taiwan is among the countries with the highest global prevalence of chronic renal disease. However, when advised to undergo dialysis therapy, patients with end-stage renal disease often hesitate. Attitudes toward medication and Taiwanese cultures are the main reasons for this delay, and delay conditioning requires urgent dialysis. This study aimed to explore the experience of urgent dialysis patients with end-stage renal disease.

Methods

This study used a purposive sampling strategy with semi-structured interviews leading to in-depth interviews. Patients were recruited from the nephrology ward and hemodialysis center of a northern Taiwanese hospital. All participants were aged over 20 years with end-stage renal disease. Although advised by doctors to undergo dialysis, these patients delayed their treatment and later suffered severe complications. After emergency hospitalization, the patients’ condition improved. Data were analyzed by content analysis.

Results

Interviews with five participants suffering from end-stage renal disease identified six themes: “experiencing a sudden jolt,” “silent organ brings the most pain,” “feeling angry: why me?,” “facing a dilemma,” “taking risks,” and “facing consequences.”

Conclusion

These patients delayed their treatment and later suffered severe complications, even though doctors advised them to undergo dialysis. Health professionals play an important role in communication and coordination, assisting patients in coping with their situation. The analysis of the reasons for the delay in undergoing dialysis, therefore, should help health professionals provide proper guidance and care to patients who are faced with the decision to accept dialysis treatment.

Treatment-related decisional conflict in pre-dialysis chronic kidney disease patients in Singapore: Prevalence and determinants

BACKGROUND

In advanced chronic kidney disease (CKD), patients face complex decisions related to renal replacement modality that can cause decisional conflict and delay. This study aimed to evaluate the prevalence of severe decisional conflict across decision types and to identify the psychosocial and clinical factors associated with decisional conflict in this population.

DESIGN

Observational cross-sectional study.

METHODS

Patients with CKD in renal care were recruited. The Decisional Conflict Scale (DCS), Functional, Communicative, and Critical Health Literacy (FCCHL), Health Literacy Questionnaire (HLQ), Hospital Anxiety and Depression Scale (HADS), Brief Illness Perception Questionnaire (BIPQ), and the Kidney-disease Quality of Life (KDQOL) questionnaires were used. Clinical data were obtained from medical records. Bivariate and multivariable logistic regression models were used to identify predictors of severe decisional conflict (DCS score ≥ 37.5).

RESULTS

Participants (N = 190; response rate = 56.7%; mean age = 62.8 ± 10.8) reported moderate levels of decisional conflict (29.7 ± 14.5). The overall prevalence of severe decisional conflict was 27.5% (n = 46) with no significant differences across decision types (dialysis, modality, access). Ethnicity (Chinese), marital status (married), BIPQ treatment control, coherence, KDQOL staff encouragement, and all health literacy domains, except functional health literacy, were significant predictors of decisional conflict in the unadjusted models. In the multivariable model, only the health literacy domains of FCCHL Communicative, and HLQ Active Engagement remained significant.

CONCLUSION

Even after pre-dialysis education, many CKD patients in this study still report severe decisional conflict, with rates remaining substantial across decision junctures. The associations of decisional conflict and health literacy skills related to communication and engagement with healthcare providers indicate that more collaborative and patient-centric pre-dialysis programs may support patient activation and resolve decisional conflict.

Social Support as a Mediator of the Relationship between Hope and Decisional Conflict in Patients Deciding Whether to Receive Dialysis

Background

The incidence rate of end-stage renal disease (ESRD) in Taiwan is the highest worldwide. Patients often hesitate and feel helpless when deciding whether to receive dialysis. However, the resulting delay in starting dialysis can potentially threaten patients' lives.

Purpose

This study aimed to understand the current situation and correlations between hope, social support, and decisional conflict among patients with ESRD deciding whether to receive dialysis. In addition, the role of social support as a mediating variable of the relationship between hope and decisional conflict was investigated.

Methods

This study was a cross-sectional, descriptive correlation study. Data, including demographic information, were collected from 85 patients with ESRD who were deciding whether to receive dialysis. Research tools included the Chinese versions of the Herth Hope Index, the Interpersonal Support Evaluation List, and the Decisional Conflict Scale.

Results

When deciding whether to receive dialysis, patients with ESRD felt a low sense of hope, a moderate degree of social support, and a moderate degree of decisional conflict. Hope was significantly correlated with social support and decisional conflict. Social support demonstrated a full mediating effect of 47.7% (P < 0.001).

Conclusions

Patients with ESRD facing the decision to receive dialysis felt a low sense of hope and exhibited decisional conflict. Social support was found to be a mediating variable of the relationship between hope and decisional conflict; therefore, medical personnel should increase the social support of patients with ESRD who are deciding whether to commence dialysis to promote patients' hope and reduce their decisional conflict.

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.

Efficacy of a decision support intervention for reducing decisional conflict in patients with elevated serum prostate-specific antigen: A randomized controlled trial

PURPOSE

The study purpose is to test the efficacy of a decision support intervention for reducing decisional conflict, increasing prostate biopsy knowledge, and enhancing decision self-efficacy in patients with elevated serum prostate-specific antigen.

METHOD

The study is based on a randomized pre-post test design. A convenience sample of men with elevated prostate-specific antigen was recruited and 1:1 randomized to the intervention and control groups. The intervention group received the decision support intervention and the control group received health education. Data were collected at the baseline and post-test by using self-reported questionnaires, including the Prostate Biopsy Knowledge Scale, the Decision Self-Efficacy Scale, the Decisional Conflict Scale, and questions regarding the prostate biopsy decision (post-test only). Data on prostate-specific antigen levels were collected from the patients' medical records.

RESULTS

A total of 110 patients participated in the study. At baseline, the intervention group had significantly higher knowledge scores than the control group. The analysis of the covariance model with the baseline score as a covariate was used to analyze the intervention effect. After controlling for the baseline scores, the mean differences (95% CI) between the two groups were 11.75 (11.17-12.32), 76.45 (72.52-80.37), and -23.53 (-26.31-20.20) for knowledge, decision self-efficacy, and decisional conflict, respectively. The between-group difference in willingness to accept prostate biopsy at the post-test was not statistically significant (χ²= 1.704).

CONCLUSIONS

The decision support intervention significantly reduced patients' decisional conflict while improving their knowledge and self-efficacy. However, the intervention did not affect patients' biopsy decision.

The patient experience of hemodialysis vascular access decision-making

BACKGROUND

To describe vascular access (VA)-related decision-making from the patient perspective, in patients who have already chosen hemodialysis as their renal replacement modality, and identify areas where physicians can improve this experience.

METHODS

In-person, semi-structured interviews with 15 patients with end-stage kidney disease were systematically analyzed by two independent researchers using thematic analysis. Interviews were conducted until systematic analysis revealed no new themes.

RESULTS

Patients had mean age 57 (range 22-85), with seven males and diverse racial/ethnic/marital status. All (15/15) patients viewed VA as "intertwined and interrelated" with dialysis, prioritized the dialysis, described the VA merely as the "hookup" to life-preserving dialysis and gave it minimal consideration. Three themes were identified: consolidation of dialysis and VA, reliance on supportive advisors and communication with physicians. Although 14/15 patients described processes common to medical decision-making, including information seeking, learning from the experiences of others, and weighing risks and benefits, they did not apply these processes specifically to VA. While all participants took ownership of the VA decision, they lacked clear understanding about the different types of VA and their consequences. Most patients (14/15) depended on family and friends for reinforcement, motivation and advice. Patients all described physician characteristics they associated with trustworthiness, the most common being listening and explaining, demonstrating empathy and making an effort to meet the patient's individual needs. Perceived arrogance, unavailability and lack of expertise represented untrustworthiness. The majority (14/15) accepted VA recommendations from physicians they found trustworthy and authoritative.

CONCLUSIONS

The study participants were minimally engaged in VA decision-making. Educational aids and shared decision-making tools are needed to empower patients to make better-informed, self-efficacious VA decisions.

Exploring the Relationship Between Patient Activation, Treatment Satisfaction, and Decisional Conflict in Patients Approaching End-Stage Renal Disease

BACKGROUND

Patients approaching end-stage renal disease (ESRD) experience a high level of decisional conflict because they are often not provided with sufficient support and information regarding different treatment options prior to renal failure. Decisional conflict is an important correlate of treatment satisfaction, as it is associated with disease- and treatment-related knowledge that can inform decision-making. Patient activation, the willingness and ability to independently manage one's own health and healthcare, is an individual difference factor that may have important mitigating effects on decisional conflict.

PURPOSE

To identify modifiable factors that may enhance the decision-making process in patients approaching ESRD by exploring potential mediational effects between decisional conflict, treatment satisfaction, and patient activation.

METHODS

Sixty-four patients approaching ESRD completed self-report measures (32% response rate). Measures included the Decisional Conflict Scale, the Kidney Disease Treatment Questionnaire, and the Patient Activation Measure Short Form.

RESULTS

There was a high level of self-reported decisional conflict in this sample. Linear regressions revealed main effects among treatment satisfaction, patient activation, and decisional conflict. These variables were entered into PROCESS to assess a mediational pattern. Results showed that higher chronic kidney disease-related treatment satisfaction predicted lower decisional conflict through higher patient activation in a statistical mediational relationship.

CONCLUSIONS

While the link between treatment satisfaction and decision-making is well established, these results suggest this relationship might be partially explained by patient activation, a potentially modifiable process in patients approaching ESRD. Therefore, interventions that encourage patients to become actively involved in their care could also reduce decisional conflict among patients approaching ESRD.

"I Wish Someone Had Told Me That Could Happen": A Thematic Analysis of Patients' Unexpected Experiences With End-Stage Kidney Disease Treatment

BACKGROUND

Preparedness regarding prognosis and treatment options enables patients to cope with uncertainties, make value-based treatment decisions, and set treatment goals. Yet, little is known about the expectedness of end-stage kidney disease (ESKD) patients' treatment experiences beyond their desire for better treatment education.

OBJECTIVE

To describe unexpected adverse treatment experiences among ESKD patients.

METHOD

The authors conducted 7 focus groups with 55 dialysis patients and living-donor kidney transplantation recipients receiving medical care in Baltimore, Maryland. Data were analyzed thematically. Themes present in different treatment groups were highlighted to provide insight into common experiences.

RESULTS

The authors identified 5 themes: (1) psychological reactions, (2) constrained freedom of choice, (3) treatment delivery and logistics, (4) morbidity, and (5) finances.

CONCLUSION

Patients were unprepared for nonclinical, logistical, and clinical aspects of ESKD treatment. The need for providers' use of tailored preparatory techniques and the development of pretreatment interventions to help patients know what to expect from and feel psychologically prepared for treatment, particularly with respect to nonclinical implications, is critical. These efforts have great potential to improve patients' treatment experiences.

Decision-making among the substitute decision makers in intensive care units: An investigation of decision control preferences and decisional conflicts

AIMS

To explore decision control preferences and decisional conflicts and to analyse their association among the surrogate decision makers in the intensive care unit.

DESIGN

The study carried out a cross-sectional survey among the surrogates.

METHODS

The participants were 115 surrogate decision makers of critical patients, from August to September 2019. A Chi-squared test and logistic regression were used to assess decision control preferences and decisional conflicts, and Spearman's rank correlation coefficient was employed to examine their association.

RESULTS

Of the 115 surrogate decision makers, 51.3% preferred a collaborative role, and 63.48% were somewhat unsure about making decisions. Logistic regression analysis identified decision control preferences was associated with surrogates' age, education level, and personality traits, while decisional conflicts was associated with surrogates' age, education level, character, medical expense burden, and Acute Physiology and Chronic Health Evaluation-II score. Cohen's kappa statistics showed a bad concordance of decision-making expectations and actuality, with kappa values of 0.158 (p < .05). Wherein surrogates who experienced discordance between their preferred and actual roles, have relatively higher decisional conflicts.

CONCLUSION

This study identified individual differences of surrogate decision makers in decision control preferences and decisional conflicts. These results imply that incorporation of the individual decision preferences and communication styles into care plans is an important first step to develop high quality decision support.

IMPACT

This research is a contribution to the limited study on decision control preferences and decisional conflicts among surrogate decision makers of critically ill patients. Moreover based on the investigation of understanding the status and related factors of decision preferences and decisional conflicts set the stage for developing effective decision support interventions.

Adaptation and Initial Psychometric Evaluation of an Informed Prostate Cancer Screening Decision Self-Efficacy Scale for African-American Men

OBJECTIVE

To evaluate whether computer-based prostate cancer screening decision aids enhance decision self-efficacy for African-American men, culturally relevant and reliable measures are needed. However, limited psychometric evidence exists on the health-related decision self-efficacy of African-American men. This study describes the development and psychometric evaluation of the 11-item Informed Prostate Cancer Screening Decision Self-Efficacy Scale among 354 African-American men.

METHODS

Exploratory factor analysis was conducted with maximum-likelihood estimation and polychoric correlations followed by Promax and Varimax rotations.

RESULTS

Exploratory factor analysis yielded a one-factor, 11-item model of the modified scale with excellent internal consistency reliability at 0.95 and factor loadings ranging from 0.70 to 0.90. Both parallel analysis and a scree plot confirmed the retention of one factor, and the standardized root mean square residual (0.06) indicated that the factor structure explained most of the correlations.

CONCLUSIONS

Findings suggest the one-factor, 11-item Informed Prostate Cancer Screening Decision Self-Efficacy Scale has excellent psychometric properties and utility in reliably measuring health-related decision self-efficacy in African-American men. Future research is needed to confirm this factor structure among socio-demographically diverse African Americans.

A Patient Decision Aid App for Patients With Chronic Kidney Disease: Questionnaire Study

BACKGROUND

The Dialysis Guide (DG) is a patient decision aid (PDA) available as an app and developed for mobile phones for patients with chronic kidney disease facing the decision about dialysis modality.

OBJECTIVE

The aim of this study was to uncover the applicability of the DG as a PDA.

METHODS

The respondents completed a questionnaire before and after using the DG. The respondents' decisional conflicts were examined using the Decisional Conflict Scale, and the usability of the app was examined using the System Usability Scale (SUS). The change in decisional conflict was determined with a paired t test.

RESULTS

A total of 22 respondents participated and their mean age was 65.05 years; 20 out of 22 (90%) had attended a patient school for kidney disease, and 13 out of 22 (59%) had participated in a conversation about dialysis choice with a health professional. After using the DG, the respondents' decisional conflicts were reduced, though the reduction was not statistically significant (P=.49). The mean SUS score was 66.82 (SD 14.54), corresponding to low usability.

CONCLUSIONS

The DG did not significantly reduce decisional conflict, though the results indicate that it helped the respondents decide on dialysis modality. Attending a patient school and having a conversation about dialysis modality choice with a health professional is assumed to have had an impact on the decisional conflict before using the DG. The usability of the DG was not found to be sufficient, which might be caused by the respondents' average age. Thus, the applicability of the DG cannot be definitively determined.

Patient engagement activities with health care professionals in continuous ambulatory peritoneal dialysis therapy: an exploratory pilot study

BACKGROUND

This pilot study aimed to explore the engagement activities between patients on continuous ambulatory peritoneal dialysis (CAPD) therapy and their health care professionals.

METHODS

An exploratory qualitative study was conducted. In-depth semi-structured interviews were undertaken involving four CAPD patients who were selected through purposive sampling. The participants were asked questions about their engagement experiences with their health care professionals.

RESULTS

Six main engagement activities were derived from the interview analysis: obtaining initial knowledge, developing knowledge and skills, feeling confident, following clinical advice, updating health condition, and supporting CAPD therapy.

CONCLUSION

Patients engagement activities played an important role in CAPD therapy. The engagement activities covered the cognitive, emotional, and behavioral dimensions. Obtaining initial knowledge as well as developing knowledge and skills are essential engagement activities before patients perform CAPD therapy.