Older patients and dialysis shared decision-making. Insights from an ethnographic discourse analysis of interviews and clinical interactions

OBJECTIVE

To describe and analyse the perspectives and communication practices of kidney clinicians and older patients (aged 60 +) during collaborative education and decision-making about dialysis.

METHODS

This qualitative study drew on pluralistic data sources and analytical approaches investigating elicited semi-structured interviews (n = 31) with doctors (n = 8), nurses (n = 8) and patients (n = 15), combined with ethnographic observations, written artefacts and audio-recorded naturally-occurring interactions (n = 23, education sessions n = 4; consultations n = 19) in a tertiary Australian kidney outpatient clinic. Data were analysed for themes and linguistic discourse features.

RESULTS

Five themes were identified across all data sources: 1) lost opportunity in education; 2) persistent disease knowledge gaps; 3) putting up with dialysis; 4) perceived and real involvement in decision-making and 5) complex role of family as decision-making brokers.

CONCLUSION

As the first study to complement interviews with evidence from naturally-occurring kidney interactions, this study balances the perspectives of how older patients and their clinicians view chronic kidney disease education, with how decision-making about dialysis is reflected in practice.

PRACTICE IMPLICATIONS

The study provides suggestions for contextualized, multi-perspectives formal and informal training for improving decision-making about dialysis, spanning from indications to boost communication efficiency, to reducing unexplained jargon, incorporating patient navigators and exploring different dialysis modalities.

Towards a better uptake of home dialysis in Europe: understanding the present and looking to the future

Use of peritoneal dialysis and home haemodialysis remains low in Europe, with the highest use in Scandinavian countries and the lowest in Eastern and Central Europe despite the advantages for people on dialysis and economic advantages for healthcare systems. This is partly due to the impact of the haemodialysis industry resulting in proliferation of haemodialysis units and nephrologist reimbursement related to use of haemodialysis. Equally important is the bias against home dialysis at both clinician and healthcare system levels. The underlying causes of this bias are discussed in relation to a mechanistic view of the human body, lack of compassion, failure to adjust dialysis provision for older age and frailty, proliferation of small dialysis centres, and complexity of decision-making and clinical care. For home dialysis to flourish, we need to foster a change in attitude to and vision of the aims of healthcare so that enabling meaningful activities of people requiring dialysis, as explored in the Standardized Outcomes in Nephrology initiative, rather than achieving biological numbers become the focus of care delivery.

Personalized peritoneal dialysis prescription-beyond clinical or analytical values

Traditionally, dialysis adequacy has been assessed primarily by determining the clearance of a single small solute, urea. Nevertheless, it has become increasingly evident that numerous other factors play a crucial role in the overall well-being, outcomes and quality of life of dialysis patients. Consequently, in recent years, there has been a notable paradigm shift in guidelines and recommendations regarding dialysis adequacy. This shift represents a departure from a narrow focus only on the removal of specific toxins, embracing a more holistic, person-centered approach. This new perspective underscores the critical importance of improving the well-being of individuals undergoing dialysis while simultaneously minimizing the overall treatment burden. It is based on a double focus on both clinical outcomes and a comprehensive patient experience. To achieve this, a person-centered approach must be embraced when devising care strategies for each individual. This requires a close collaboration between the healthcare team and the patient, facilitating an in-depth understanding of the patient's unique goals, priorities and preferences while striving for the highest quality of care during treatment. The aim of this publication is to address the existing evidence on this all-encompassing approach to treatment care for patients undergoing peritoneal dialysis and provide a concise overview to promote a deeper understanding of this person-centered approach.

Delivering Person-Centered Peritoneal Dialysis

Peritoneal dialysis (PD) enables people to have a home-based therapy, permitting greater autonomy for individuals along with enhanced treatment satisfaction compared with in-center dialysis care. The burden of treatment on PD, however, remains considerable and underpins the need for person-centered care. This reflects the need to address the patient as a person with needs and preferences beyond just the medical perspective. Shared decision making is central to the recent International Society for Peritoneal Dialysis recommendations for prescribing PD, balancing the potential benefits of PD on patient well-being with the burden associated with treatment. This review considers the role of high-quality goal-directed prescribing, incremental dialysis, and remote patient monitoring in reducing the burden of dialysis, including an approach to implementing incremental PD. Although patient-related outcomes are important in assessing the response to treatment and, particularly life participation, the corollary of dialysis burden, there are no clear routes to the clinical implementation of patient-related outcome measures. Delivering person-centered care is dependent on treating people both as individuals and as equal partners in their care.

Shared decision making in chronic kidney disease: a qualitative study of the impact of communication practices on treatment decisions for older patients

BACKGROUND

Effective interpersonal communication is critical for shared decision-making (SDM). Previous SDM communication training in nephrology has lacked context-specific evidence from ethnographic analysis of SDM interactions with older patients considering treatment options of end stage kidney disease (ESKD). This study explores communication strategies in SDM discussions in nephrology, specifically focusing on older patients considering dialysis as kidney replacement therapy (KRT).

METHODS

We conducted a qualitative study analysing naturally-occurring audio-recorded clinical interactions (n = 12) between Australian kidney doctors, patients aged 60+, and carers. Linguistic ethnography and qualitative socially-oriented functional approaches were used for analysis.

RESULTS

Two types of communication strategies emerged: (1) Managing and advancing treatment decisions: involving active checking of knowledge, clear explanations of options, and local issue resolution. (2) Pulling back: Deferring or delaying decisions through mixed messaging. Specifically for non-English speaking patients, pulling back was further characterised by communication challenges deferring decision-making including ineffective issue management, and reliance on family as interpreters. Age was not an explicit topic of discussion among participants when it came to making decisions about KRT but was highly relevant to treatment decision-making. Doctors appeared reluctant to broach non-dialysis conservative management, even when it appears clinically appropriate. Conservative care, an alternative to KRT suitable for older patients with co-morbidities, was only explicitly discussed when prompted by patients or carers.

CONCLUSIONS

The findings highlight the impact of different communication strategies on SDM discussions in nephrology. This study calls for linguistic-informed contextualised communication training and provides foundational evidence for nephrology-specific communication skills training in SDM for KRT among older patients. There is urgent need for doctors to become confident and competent in discussing non-dialysis conservative management. Further international research should explore naturally-occurring SDM interactions in nephrology with other vulnerable groups to enhance evidence and training integration.

Delivering Personalized, Goal-Directed Care to Older Patients Receiving Peritoneal Dialysis

Background

An aging population living with chronic kidney disease and progressing to kidney failure, subsequently receiving peritoneal dialysis (PD) is growing. A significant proportion of these patients are also living with multi-morbidities and some degree of frailty. Recent practice recommendations from the International Society of Peritoneal Dialysis advocate for high-quality, goal-directed PD prescription, and the Standardized Outcomes of Nephrology-PD initiative emphasized the need for an individualized, goal-based care approach in all patients receiving PD treatment. In older patients, this approach to PD care is even more important. A frailty screening assessment, followed by a comprehensive geriatric assessment (CGA) prior to PD initiation and when dictated by change in relevant circumstances is paramount in tailoring PD care and prescription according to the needs, life goals, as well as clinical status of older patients with kidney failure.

Summary

Our review aimed to summarize the different dimensions to be taken into account when delivering PD care to the older patient - from frailty screening and CGA in older patients receiving PD to employing a personalized, goal-directed PD prescription strategy, to preserving residual kidney function, optimizing blood pressure (BP) control, and managing anemia, to addressing symptom burden, to managing nutritional intake and promoting physical exercise, and to explore telehealth opportunities for the older PD population.

Key Messages

What matters most to older PD patients may not be simply extending survival, but more importantly, to be living comfortably on PD treatment with minimal symptom burden in a home environment and to minimize treatment complications.

Effects of one-hour discussion on the choice of dialysis modality at the outpatient clinic: A retrospective cohort study using propensity score matching

BACKGROUND

The aim of present study was to evaluate the effects of one-hour discussion on the choice of dialysis modality at the outpatient clinic.

METHODS

Charts of consecutive patients who had started maintenance dialysis from May 2013 to April 2021 were retrospectively reviewed. Characteristics at the start of dialysis were compared between patients participated and not participated in the discussion.

RESULTS

Of the 620 incident dialysis patients, 128 patients had participated in the discussion. After propensity score matching (1:1), 127 patients who participated in the discussion tended to have fewer urgent hospitalizations (13.4% vs. 21.3%, p = 0.068). In addition, more patients who initiated peritoneal dialysis (PD) (30.7% vs. 9.4%, p < 0.001). On multivariate analysis, participation in the discussion (OR 4.81, 95% CI 2.807-8.24; p < 0.001) was related to PD initiation.

CONCLUSION

One-hour discussion on the choice of dialysis modality may increase PD initiations and decrease the number of urgent hospitalizations.

Choice of the Dialysis Modality: Practical Considerations

Chronic kidney disease and the need for kidney replacement therapy have increased dramatically in recent decades. Forecasts for the coming years predict an even greater increase, especially in low- and middle-income countries, due to the rise in metabolic and cardiovascular diseases and the aging population. Access to kidney replacement treatments may not be available to all patients, making it especially strategic to set up therapy programs that can ensure the best possible treatment for the greatest number of patients. The choice of the "ideal" kidney replacement therapy often conflicts with medical availability and the patient's tolerance. This paper discusses the pros and cons of various kidney replacement therapy options and their real-world applicability limits.

Peritoneal catheter insertion: combating barriers through policy change

Barriers to accessing home dialysis became a matter of life and death for many patients with kidney failure during the coronavirus disease 2019 (COVID-19) pandemic. Peritoneal dialysis (PD) is the more commonly used home therapy option. This article provides a comprehensive analysis of PD catheter insertion procedures as performed around the world today, barriers impacting timely access to the procedure, the impact of COVID-19 and a roadmap of potential policy solutions. To substantiate the analysis, the article includes a survey of institutions across the world, with questions designed to get a sense of the regulatory frameworks, barriers to conducting the procedure and impacts of the pandemic on capability and outcomes. Based on our research, we found that improving patient selection processes, determining and implementing correct insertion techniques, creating multidisciplinary teams, providing appropriate training and sharing decision making among stakeholders will improve access to PD catheter insertion and facilitate greater uptake of home dialysis. Additionally, on a policy level, we recommend efforts to improve the awareness and feasibility of PD among patients and the healthcare workforce, enhance and promulgate training for clinicians—both surgical and medical—to insert PD catheters and fund personnel, pathways and physical facilities for PD catheter insertion.

Optimised versus standard automated peritoneal dialysis regimens pilot study (OptiStAR): A randomised controlled crossover trial

BACKGROUND

The continuous global rise of end-stage kidney disease creates a growing demand of economically beneficial home-based kidney replacement therapies such as peritoneal dialysis (PD). However, undesirable absorption and exposure of peritoneal tissues to glucose remain major limitations of PD.

METHODS

We compared a reference (standard) automated PD regimen 6 × 2 L 1.36% glucose (76 mmol/L) over 9 h with a novel, theoretically glucose sparing (optimised) prescription consisting of 'ultrafiltration cycles' with high glucose strength (126 mmol/L) and 'clearance cycles' with ultra-low, physiological glucose (5 mmol/L) for approximately 40% of the treatment time. Twenty-one prevalent PD patients underwent the optimised regimen (7 × 2 L 2.27% glucose + 5 × 2 L 0.1% glucose over 8 h) and the standard regimen in a crossover fashion. Six patients were excluded from data analysis.

RESULTS

Median glucose absorption was 43 g (IQR 41-54) and 44 g (40-55) for the standard and optimised intervention, respectively (p = 1). Ultrafiltration volume, weekly Kt/V creatinine and urea were significantly improved during optimised interventions, while no difference in sodium removal was detected. Post hoc analysis showed significantly improved ultrafiltration efficiency (ml ultrafiltration per gram absorbed glucose) during optimised regimens. No adverse events were observed except one incidence of drain pain.

CONCLUSION

Optimised treatments were feasible and well tolerated in this small pilot study. Despite no difference in absorbed glucose, results indicate possible improvements of ultrafiltration efficiency and small solute clearances by optimised regimens. Use of optimised prescriptions as glucose sparing strategy should be evaluated in larger study populations.

Kidney Supportive Care in Peritoneal Dialysis: Developing a Person-Centered Kidney Disease Care Plan

Individuals receiving peritoneal dialysis (PD)—similar to those receiving hemodialysis —may experience high mortality coupled with a high symptom burden and reduced health-related quality of life. In this context, a discussion of the risks, benefits, and tradeoffs of PD and/or other kidney treatment modalities should be explored based on individual goals and preferences. Through these principles, kidney supportive care provides a person-centered approach to kidney disease care throughout the spectrum of kidney failure and earlier stages of chronic kidney disease. Kidney supportive care is offered in conjunction with life-prolonging therapies, including dialysis and kidney transplants, and is increasingly recognized as an integral part of advancing the care of PD patients. Using “My Kidney Care Roadmap” for shared decision making, kidney supportive care guides patients undergoing PD and their clinicians to (1) elicit patient goals, values, and priorities; (2) convey medical prognosis and suitable treatment options; and (3) ask “Which of these kidney treatment options will best help me achieve my goals and priorities?” to inform both current and future decisions, including choice of dialysis modalities, time-limited trials, and/or nondialysis management. Recognizing that patient priorities and choices may evolve, this framework ultimately allows patients to continually reassess their PD care to better achieve goal-directed dialysis.

Automated Peritoneal Dialysis: Patient Perspectives and Outcomes

A steadily increasing number of end stage kidney disease (ESKD) patients are maintained on automated peritoneal dialysis (APD) worldwide, in long-standing as well as in more recently established peritoneal dialysis (PD) programs. A better understanding of the technique, paralleled by progress in involved technology, sustained this growth to the point that APD has become the prevalent mode of PD delivery in most high-income countries. While APD is now regarded to be at least as efficient as continuous ambulatory peritoneal dialysis (CAPD) with regard to major biomedical outcomes, its impact on patient-reported outcomes has been less investigated. This paper reviews the main outcomes of APD from a clinical point of view and from the person on dialysis perspective.

Comparison of shared decision making in patients undergoing hemodialysis and peritoneal dialysis for choosing a dialysis modality

Background

Shared decision making (SDM) is recognized as the gold standard for patient-centered care. This study aimed to assess and compare the SDM among patients undergoing hemodialysis and peritoneal dialysis for choosing a dialysis modality.

Methods

This is a cross-sectional study that was performed on 300 dialysis patients (218 HD and 82 PD) referred to two Dialysis Centers. Data were collected using demographic information and a 9-item Shared Decision Making Questionnaire (SDM-Q-9). The data were analyzed using ANOVA and independent t-test by SPSS software.

Results

The mean SDM-Q-9 score in all samples (PD and HD) was 21.94 ± 15.08 (in a possible range of 0 to 45). Results of the independent t-test showed that the mean SDM-Q-9 score in PD patients (33.11 ± 10.08) was higher than HD patients (17.14 ± 74.24) (p < 0.001). The results showed a statistically significant difference in mean SDM-Q-9 score based on patients’ age, educational level, and income (p < 0.05).

Conclusion

Implementing shared decision making and providing information on RRT should be started in the early stage of CKD. The health care providers should involve patients with CKD and their families in dialysis-related decisions and it should be started in the early stage of CKD.

Need for evidence on long-term prognosis of PD+HD: a commentary

Combination therapy with peritoneal dialysis and hemodialysis (PD+HD) is an alternative dialysis method for patients with end-stage kidney disease (ESKD). The complementary use of once-weekly HD expedites to achieve adequate dialysis and enables to prolong PD duration. Although PD+HD has been widely employed among Japanese PD patients, it is much less common outside Japan. Clinical evidences are still not enough, especially in long-term prognosis and appropriate treatment duration, suitable patients, and generalizability. A retrospective cohort study by Chung et al. (BMC Nephrol 21:348, 2020) compared the risk of mortality and hospitalization between PD patients who were transferred to PD+HD and those who were transferred to HD in Taiwan. Because the mortality and hospitalization rates did not differ between the groups, the authors concluded that, PD+HD may be a rational and cost-effective treatment option. It should be noted that the effects of PD+HD on long-term prognosis are still unknown due to too-short PD+HD duration. However, the study identified the high-risk patient population and showed the generalizability of PD+HD. PD+HD is a treatment of choice in patients with ESKD who prefer PD lifestyles even after decline in residual kidney function.

Peritoneal dialysis patient selection from a comorbidity perspective

Despite many medical and socioeconomic advantages, peritoneal dialysis (PD) is an underutilized dialysis modality that in most countries is used by only 5%-20% of dialysis patients, while the vast majority are treated with in-center hemodialysis. Several factors may explain this paradox, such as lack of experience and infrastructure for training and monitoring of PD patients, organizational issues, overcapacity of hemodialysis facilities, and lack of economic incentives for dialysis centers to use PD instead of HD. In addition, medical conditions that are perceived (rightly or wrongly) as contraindications to PD represent barriers for the use of PD because of their purported potential negative impact on clinical outcomes in patients starting PD. While there are few absolute contraindications to PD, high age, comorbidities such as diabetes mellitus, obesity, polycystic kidney disease, heart failure, and previous history of abdominal surgery and renal allograft failure, may be seen (rightly or wrongly) as relative contraindications and thus barriers to initiation of PD. In this brief review, we discuss how the presence of these conditions may influence the strategy of selecting patients for PD, focusing on measures that can be taken to overcome potential problems.

Incremental peritoneal dialysis

Incremental peritoneal dialysis (PD) has been variably defined. It involves taking advantage of the residual renal function that is usually present at initiation of dialysis to initially prescribe less onerous lower doses of PD while still achieving individualized clearance goals. We propose that incremental PD be defined as a strategy, rather than a particular regime, in which: (1) less than standard “full-dose” PD is initially prescribed in recognition of the value of residual renal function; (2) peritoneal clearance is initially less than the individualized clearance goal but the combination of peritoneal plus renal clearance achieves or exceeds that goal clearance; and (3) there is a clear intention to increase dose of PD as renal clearance declines and/or symptoms appear.

Incremental PD by its nature lessens the workload of dialysis for those doing PD, reduces cost and exposure of the peritoneal membrane to glucose, and may lessen mechanical symptoms. Evidence that incremental PD improves clinical outcomes compared to the use of full-dose PD is lacking but one randomized controlled trial, multiple observational studies, and a systematic review all suggest that outcomes are at least as good. Given that incremental PD costs less and is inherently less onerous, it is reasonable, pending larger randomized trials, to adopt this strategy.