Time to Improve Informed Consent for Dialysis: An International Perspective

Protocol for a hybrid effectiveness-implementation clinical trial evaluating video-assisted electronic consent vs standard consent for patients initiating and continuing haemodialysis in Australia (eConsent HD)

INTRODUCTION

Communicating complex information about haemodialysis (HD) and ensuring it is well understood remains a challenge for clinicians. Informed consent is a high-impact checkpoint in augmenting patients' decision awareness and engagement prior to HD. The aims of this study are to (1) develop a digital information interface to better equip patients in the decision-making process to undergo HD; (2) evaluate the effectiveness of the co-designed digital information interface to improve patient outcomes; and (3) evaluate an implementation strategy.

METHODS AND ANALYSIS

First, a co-design process involving consumers and clinicians to develop audio-visual content for an innovative digital platform. Next a two-armed, open-label, multicentre, randomised controlled trial will compare the digital interface to the current informed consent practice among adult HD patients (n=244). Participants will be randomly assigned to either the intervention or control group. Intervention group: Participants will be coached to an online platform that delivers a simple-to-understand animation and knowledge test questions prior to signing an electronic consent form.

CONTROL GROUP

Participants will be consented conventionally by a clinician and sign a paper consent form. Primary outcome is decision regret, with secondary outcomes including patient-reported experience, comprehension, anxiety, satisfaction, adherence to renal care, dialysis withdrawal, consent time and qualitative feedback. Implementation of eConsent for HD will be evaluated concurrently using the Consolidation Framework for Implementation Research (CFIR) methodology.

ANALYSIS

For the randomised controlled trial, data will be analysed using intention-to-treat statistical methods. Descriptive statistics and CFIR-based analyses will inform implementation evaluation.

ETHICS AND DISSEMINATION

Human Research Ethics approval has been secured (Metro North Health Human Research Ethics Committee B, HREC/2022/MNHB/86890), and Dissemination will occur through partnerships with stakeholder and consumer groups, scientific meetings, publications and social media releases.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry (ACTRN12622001354774).

Short-term and long-term survival in patients with prevalent haemodialysis-an integrated prognostic model: external validation

OBJECTIVES

Prognostic tools with evidence for external validity in routine clinical practice are needed to align care with patients' preferences and deliver timely supportive services. Current models have limited, if any, evidence for external validity and none have been implemented and evaluated in clinical practice on a large scale. This study sought to provide evidence for external validity in a real life setting of the Cohen prognostic model that integrates actuarial factors with the 'Surprise Question' to assess 6-month, 12-month and 18-month survival of prevalent haemodialysis patients.

METHODS

Cross-sectional study of 1372 patients in a Canadian university-based programme between 2010 and 2019. Survival probabilities were compared with observed survival. Discrimination and calibration were assessed through predicted risk-stratified observed survival, cumulative AUC, Somer's Dxy and a calibration slope estimate.

RESULTS

Discrimination performance was moderate with a C statistic of 0.71-0.72 for all three time points. The model overpredicted mortality risk with the best predictive accuracy for 6- month survival. The differences between observed and mean predicted survival at 6 months, 12 months and 18 months were 3.2%, 8.8% and 12.9%, respectively. Kaplan-Meier curves stratified by Cox-based risk group showed good discrimination between high-risk and low-risk patients with HR estimates (95% CI): C2 vs C1 3.07 (1.57-5.99), C3 vs C1 5.85 (3.06-11.17), C4 vs C1 13.24 (6.91-25.34)).

CONCLUSIONS

The Cohen prognostic model can be incorporated easily into routine dialysis care to identify patients at high risk for death over 6 months, 12 months and 18 months and help target vulnerable patients for timely supportive care interventions.

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.

Uncovering Patient and Caregiver Goals for Goal-Concordant Care in Kidney Therapy Decisions

CONTEXT

In kidney therapy (KT) decisions, goal-concordant decision-making is recognized to be important, yet alignment with patients' goals during dialysis initiation is not always achieved.

OBJECTIVES

To explore older patients' and caregivers' hopes, goals, and fears related to KT and communication of these elements with members of their health care team.

METHODS

The study included patients aged ≥75 years with an estimated glomerular filtration rate ≤25 mL/min/1.73 m2 and their caregivers enrolled in a palliative care intervention for KT decision-making. Patients and caregivers were asked open-ended questions about their hopes, goals, and fears related to KT decisions. A survey assessed if patients shared their goals with members of their health care team. Qualitative data underwent content analysis, supplemented by demographic descriptive statistics.

RESULTS

The mean age of patients (n = 26) was 82.7 (±5.7) years, and caregivers (n = 15) had a mean age of 66.4 (±13.7) years. Among the participants, 13 patients and 11 caregivers were women, and 20 patients and 12 caregivers were White. Four themes emerged: (1) Maintaining things as good as they are by avoiding dialysis-related burdens; (2) seeking longevity while avoiding dialysis; (3) avoiding pain, symptoms, and body disfigurement; and (4) deferring decision-making. Patients rarely had shared their goals with the key members of their health care team.

CONCLUSION

Patients and caregivers prioritize maintaining quality of life, deferring decision-making regarding dialysis, and avoiding dialysis-related burdens. These goals are often unshared with their family and health care teams. Given our aging population, urgent action is needed to educate clinicians to actively explore and engage with patient goals in KT decision-making.

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.

Comprehensive conservative care: what doctors say, what patients hear

The demographic evolution of patients with advanced chronic kidney disease (CKD) has led to the advent of an alternative treatment option to kidney replacement therapy in the past couple of decades. The KDIGO controversies on Kidney Supportive Care called this approach "comprehensive conservative care" (CCC) and defined it as planned holistic patient-centered care for patients with CKD stage 5 that does not include dialysis. Although the benefit of this treatment option is now well-recognized, especially for the elderly, and comorbid and frail patients, its development remains limited in practice. While shared decision-making and advance care planning represent the cornerstones of the CCC approach, one of the main barriers in its development is the perfectible communication between nephrologists and patients, but also between all healthcare professionals involved in the care of advanced CKD patients. As a result, a significant gap has opened up between what doctors say and what patients hear. Indeed, although CCC is reported by nephrologists to be widely available in their facilities, few of their patients say that they have actually heard of it. The objectives of this review are to explore discrepancies between what doctors say and what patients hear, to identify the factors underlying this gap, and to formulate practical proposals for narrowing this gap in practice.

Development and Acceptability of a Kidney Therapy Decision Aid for Patients Aged 75 Years and Older: A Design-Based Research Involving Patients, Caregivers, and a Multidisciplinary Team

Rationale & Objective

Many older adults prefer quality of life over longevity, and some prefer conservative kidney management (CKM) over dialysis. There is a lack of patient-decision aids for adults aged 75 years or older facing kidney therapy decisions, which not only include information on dialysis and CKM but also encourage end-of-life planning. We iteratively developed a paper-based patient-decision aid for older people with low literacy and conducted surveys to assess its acceptability.

Study Design

Design-based research.

Setting and Participants

Informed by design-based research principles and theory of behavioral activation, a multidisciplinary team of experts created a first version of the patient-decision aid containing 2 components: (1) educational material about kidney therapy options such as CKM, and (2) a question prompt list relevant to kidney therapy and end-of-life decision making. On the basis of the acceptability input of patients and caregivers, separate qualitative interviews of 35 people receiving maintenance dialysis, and with the independent feedback of educated layperson, we further modified the patient-decision aid to create a second version.

Analytical Approach

We used descriptive statistics to present the results of acceptability surveys and thematic content analyses for patients' qualitative interviews.

Results

The mean age of patients (n=21) who tested the patient-decision aid was 80 years and the mean age of caregivers (n=9) was 70 years. All respondents held positive views about the educational component and would recommend the educational component to others (100% patients and caregivers). Most of the patients reported that the question prompt list helped them put concerns into words (80% patients and 88% caregivers) and would recommend the question prompt list to others (95% patients and 100% caregivers).

Limitations

Single-center study.

Conclusions

Both components of the patient-decision aid received high acceptability ratings. We plan to launch a larger effectiveness study to test the outcomes of a decision-supporting intervention combining the patient-decision aid with palliative care-based decision coaching.

Dialysis Access Considerations in Kidney Palliative Care

In this review, we discuss common challenges at the interface between dialysis access planning, prognostication, and patient-centered decision making. Particularly for patients whose survival benefit from dialysis is attenuated by advanced age or other serious illness, knowing the potential complications and anticipated frequency of access procedures is essential for patients and families to be able to conceptualize what life on dialysis will look like. Although starting dialysis with a functioning graft or fistula is associated with reduced infection rates, mortality, hospitalizations, and cost compared with a central venous catheter, these benefits must be weighed against the chance that early access placement in an elderly or seriously ill patient is an unnecessary surgery because the chronic kidney disease never progresses, the patient dies before developing an indication to start dialysis, or, the patient prefers conservative kidney management over dialysis. Kidney palliative care is a growing subspecialty of nephrology focused on helping seriously ill patients navigate complex medical decisions, and may be useful for intensive goals-of-care discussions about treatment and access options for patients with limited anticipated survival because of age or other serious illness.

Conservative Kidney Management: When, Why, and For Whom?

Deciding between dialysis and conservative kidney management (CKM) in an elderly or seriously ill person with kidney failure is complex and requires shared decision making. Patients and families look to their nephrologist to provide an individualized recommendation that aligns with patient-centered goals. For a balanced and considered decision to be made, dialysis should not be the default and nephrologists need to be familiar with relevant prognostic information including survival, symptom burden, functional trajectory, and quality of life with dialysis and with CKM. CKM is a holistic, proactive, and multidisciplinary treatment for kidney failure. For some elderly comorbid patients, CKM improves symptom burden and aligns with quality-of-life goals, with modest or no loss of longevity. CKM can be provided by a nephrologist alone but ideally is managed through partnership with a dedicated supportive or palliative care service embedded within the nephrology practice. Treatment decisions are best discussed early in the disease trajectory and occur over many consultations, and nephrologists should be upskilled in communication to better support patients and families in these important conversations. Nephrologists should remain actively involved in their patients' care through to end-of-life care.

Dialysis Organization Online Information on Kidney Failure Treatments: A Content Analysis Using Corpus Linguistics

Rationale & Objective

Dialysis organizations’ websites may influence patient decision making, but the websites have received almost no consideration. We investigated how/whether these websites present all kidney replacement therapy options and how the quality of life of these options is portrayed.

Study Design

Content analysis using corpus linguistics (computer-assisted language analysis).

Setting

Website content aimed at patients from the 2 major dialysis organizations’ websites, totaling 226,968 words. The analysis took place from November 12, 2020, to March 30, 2021.

Analytical Approach

We used linguistic software (AntConc) to document the frequencies of words needed to present treatment options and quality of life information.

Results

Over both sites, dialysis mentions outstripped transplantation mentions. Organization A did not appear to reference conservative kidney management. Organization B mentioned dialysis more often than conservative management, at a ratio of 34:1. Organization A did not attribute symptoms to dialysis, whereas organization B had 12 mentions of dialysis-induced symptoms out of 87 total symptom references. Both organizations framed life on dialysis optimistically, suggesting that patients can continue to engage in “work,” “sex,” or “travel”; organization A referenced sex, work, and/or travel 123 times and organization B referenced these 262 times.

Limitations

We used quantitative analysis and linked ideas with certain keywords. We did not conduct a detailed qualitative inquiry.

Conclusions

The websites emphasized dialysis as a treatment for kidney failure, and the quality of life on dialysis was framed very optimistically. Qualitative studies of treatment modalities and the quality of life on dialysis in the patient-targeted material of dialysis organizations are needed.

Changing landscape of dialysis withdrawal in patients with kidney failure: Implications for clinical practice

Dialysis withdrawal has become an accepted treatment option for patients with kidney failure and is one of the leading causes of death in patients receiving dialysis in high-income countries. Despite its increasing acceptance, dialysis withdrawal currently lacks a clear, consistent definition. The processes and outcomes of dialysis withdrawal have wide temporal and geographical variability, attributed to dialysis patient selection, influence from cultural, religious and spiritual beliefs, and availability of kidney replacement therapy and conservative kidney management. As a complex, evolving process, dialysis withdrawal poses an enormous challenge for clinicians and healthcare teams with various limitations precluding a peaceful and smooth transition between active dialysis and end-of-life care. In this review, we examine the current definitions of dialysis withdrawal, the temporal and geographical patterns of dialysis withdrawal, international barriers in the decision-making process (including dialysis withdrawal during the COVID-19 pandemic), and gaps in the current dialysis withdrawal recommendations for clinical consideration and future studies.

A Systematic Literature Review of Relational Autonomy in Dialysis Decision Making

Nephrology interdisciplinary guidelines, professional codes of ethics, principle-based ethical standards, and literature promote patient autonomy and self-determination through shared decision making as ethical practice. Healthcare professionals are accountable for practice that is mindful of the impact of cultural diversity and community on the values and beliefs of the patient, an important part of shared decision making (SDM). Despite previous research regarding dialysis decision making, relational autonomy in chronic kidney disease (CKD) and end-stage kidney disease SDM conversations is not well understood. This systematic literature review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework for identifying peer-reviewed literature on SDM for CKD. The findings were summarized into four broad themes: (1) promoting autonomy is a foundation of medical caring; (2) providers have a responsibility to respond to their asymmetrical social power; (3) autonomy is situated within the context of the patient; and (4) dialogue is a tool that negotiates clinical recommendations and patient goals. The caring practices of promoting autonomy with a dialogical resolution of a conflict acknowledging the interdependence of the parties and the patient's social-relational situatedness support a perspective of relational autonomy in dialysis decision-making practice and research.

A rapid scoping review of end-of-life conversations with frail older adults in Canada

OBJECTIVE

To explore what is known about end-of-life (EOL) conversations with frail older adults across all settings including primary care in Canada, and to understand the barriers to, and recommendations for, EOL conversations.

DATA SOURCES

Comprehensive searches were conducted in CINAHL (EBSCO), Embase (Ovid), MEDLINE (Ovid), AgeLine (EBSCO), Sociological Abstracts (ProQuest), and Applied Social Sciences Index and Abstracts (ProQuest). Searches used text words and subject headings (eg, MeSH, Emtree) related to 3 concepts: frailty, Canada, and EOL conversations.

STUDY SELECTION

Twenty-one English-language articles were selected (ie, 4 reviews, 10 commentaries, 3 quantitative studies, 3 qualitative studies, 1 mixed-methods study) that included information about EOL conversations with frail older adults in the Canadian health care context.

SYNTHESIS

In terms of having EOL conversations with frail older adults, this study found that many clinicians do not often and adequately discuss frailty and impending death with their older patients. Moreover, patients and their care partners do not have enough knowledge about frailty and death to make informed EOL decisions, leading to patients choosing more aggressive therapies instead of care focused on symptom management. In terms of barriers to EOL discussions, common barriers included a lack of trust between clinician and patient, inadequate EOL training for clinicians, and ineffective clinician communication with patients and families. Recommendations for improving EOL conversations include regular screening for frailty to prompt conversations about care and the use of an interprofessional approach.

CONCLUSION

More empirical research is needed that uses exploratory methods to shed light on the contextual factors that may act as a barrier to EOL conversations. More research is also needed on the roles and responsibilities of interprofessional teams in screening for frailty and engaging in EOL conversations. Moreover, there is a need to better understand how frail older patients and their families want EOL conversations to unfold and what best facilitates these conversations.

Communication principles and practices for making shared decisions about renal replacement therapy: a review of the literature

PURPOSE OF REVIEW

To provide an overview of the skill set required for communication and person-centered decision making for renal replacement therapy (RRT) choices, especially conservative kidney management (CKM).

RECENT FINDINGS

Research on communication and decision-making skills for shared RRT decision making is still in infancy. We adapt literature from other fields such as primary care and oncology for effective RRT decision making.

SUMMARY

We review seven key skills: (1) Announcing the need for decision making (2) Agenda Setting (3) Educating patients about RRT options (4) Discussing prognoses (5) Eliciting patient preferences (6) Responding to emotions and showing empathy, and (7) Investing in the end. We also provide example sentences to frame the conversations around RRT choices including CKM.

Temporal changes and risk factors of death from early withdrawal within 12 months of dialysis initiation - a cohort study

Background

Mortality risk is high soon after dialysis initiation in patients with kidney failure, and dialysis withdrawal is a major cause of early mortality, attributed to psychosocial or medical reasons. The temporal trends and risk factors associated with cause-specific early dialysis withdrawal within 12 months of dialysis initiation remain uncertain.

Methods

Using data from the Australia and New Zealand Dialysis and Transplant Registry, we examined the temporal trends and risk factors associated with mortality attributed to early psychosocial and medical withdrawals in incident adult dialysis patients in Australia between 2005 and 2018 using adjusted competing risk analyses.

Results

Of 32 274 incident dialysis patients, 3390 (11%) experienced death within 12 months post-dialysis initiation. Of these, 1225 (36%) were attributed to dialysis withdrawal, with 484 (14%) psychosocial withdrawals and 741 (22%) medical withdrawals. These patterns remained unchanged over the past two decades. Factors associated with increased risk of death from early psychosocial and medical withdrawals were older age, dialysis via central venous catheter, late referral and the presence of cerebrovascular disease; obesity and Asian ethnicity were associated with decreased risk. Risk factors associated with early psychosocial withdrawals were underweight and higher socioeconomic status. Presence of peripheral vascular disease, chronic lung disease and cancers were associated with early medical withdrawals.

Conclusions

Death from dialysis withdrawal accounted for >30% of early deaths in kidney failure patients initiated on dialysis and remained unchanged over the past two decades. Several shared risk factors were observed between mortality attributed to early psychosocial and medical withdrawals.

A working partnership: A review of shared decision-making in nephrology

Patients with chronic kidney disease are required to make difficult decisions, negotiating between the risks, burdens and benefits for any proposed course. This process can be extremely challenging, since these decisions involve inherent risks, which can impact on survival and quality of life. Shared decision-making offers a patient-centred approach in partnering with patients to make decisions about their treatment, which reflect their values and preferences. Shared decision-making can improve patient preparedness, motivation, satisfaction, and adherence to the treatment or decision agreed upon. In this review article, we outline the key principles of shared decision-making, and provide a framework with communication strategies to facilitate shared decision-making. We highlight the broad range and context of decisions faced by patients in several areas of nephrology care and discuss patient-important outcomes, priorities and motivations that underpin their decision-making. Preserving patient autonomy through shared decision-making ensures close consideration of patient preferences to enhance satisfaction with the decision reached and optimize outcomes important to patients.

Ethical Duties of Nephrologists: When Patients Are Nonadherent to Treatment

When providing care, nephrologists are subject to various ethical duties. Beyond the Hippocratic notion of doing no harm, nephrologists also have duties to respect their patients' autonomy and dignity, to meet their patients' care goals in the least invasive way, to act impartially, and, ultimately, to do what is (clinically) beneficial for their patients. Juggling these often-conflicting duties can be challenging at the best of times, but can prove especially difficult when patients are not fully adherent to treatment. When a patient's nonadherence begins to cause harm to themselves and/or others, it may be questioned whether discontinuation of care is appropriate. We discuss how nephrologists can meet their ethical duties when faced with nonadherence in patients undergoing hemodialysis, including episodic extreme agitation, poor renal diet, missed hemodialysis sessions, and emergency presentations brought on by nonadherence. Furthermore, we consider the impact of cognitive impairment and provider-family conflict when making care decisions in a nonadherence context, as well as how the coronavirus disease 2019 pandemic might affect responses to nonadherence. Suggestions are provided for ethically informed responses, prioritizing a patient-narrative approach that is attentive to patients' values and preferences, multidisciplinarity, and the use of behavioral contracts and/or technology where appropriate.

Dialysis decisions concerning cognitively impaired adults: a scoping literature review

Background

Chronic kidney disease is a significant cause of global deaths. Those who progress to end-stage kidney disease often commence dialysis as a life-extending treatment. For cognitively impaired patients, the decision as to whether they commence dialysis will fall to someone else. This scoping review was conducted to map existing literature pertaining to how decisions about dialysis are and should be made with, for, and on behalf of adult patients who lack decision-making capacity. In doing so, it forms the basis of a larger body of work that is exploring how these decisions ought to be made.

Methods

To identify relevant papers, searches were conducted on Ovid MEDLINE(R), Embase, PsychINFO, The Cochrane Library, and Web of Science. Inclusion criteria were then applied, requiring that papers: report on empirical studies about how decisions about dialysis are made and/or discuss how decisions about dialysis should be made with, for, and on behalf of adult patients who lack decision-making capacity; be published from 1961 onwards; and be published in English. This resulted in 27 papers eligible for inclusion.

Results

Of note, the majority of papers originated in the United States. There was wide variation across the included papers. Extracted data were grouped under the following themes: involving various parties (patient involvement, family dominance, and wider communication); objectivity about care options (including difficulties with family detachment); cultural sensitivity; medical versus non-medical factors; managing nonadherent patients; and the role and prevalence of substituted judgement. The literature shows that there is inconsistency in the principles and processes surrounding decisions made about dialysis with, for, and on behalf of adult patients who lack decision-making capacity.

Conclusions

This scoping review demonstrates that there is significant variation in both the practice and theory of dialysis decision making with, for, and on behalf of cognitively impaired adult patients. Complexity arises in considering who should get a say, how influential their say should be in a decision, and what factors are most relevant to the decision. A lack of up-to-date literature exploring this issue is highlighted, with this scoping review providing a useful groundwork from which further research can be undertaken.

[Treatment of geriatric patients with end-stage renal failure : Dialysis or conservative procedure?]

Compared to younger patients, an acceptable state of health in older patients with various comorbidities is rarely achieved by the initiation of dialysis. Despite dialysis treatment, further functional and cognitive impairments often rapidly occur in geriatric patients. Thus, newer studies are concerned with the quality of life of this patient group after initiation of dialysis as well as with palliative treatment strategies as alternatives. A structured clarification for the patients on all possibilities with mediation of all necessary information is a prerequisite for a shared decision-making. To assess life expectancy after dialysis initiation, various scores have been developed but the sensitivity could not fulfil the expectations. In the case of renal replacement, chronic intermittent hemodialysis is the treatment form most frequently performed in geriatric patients. The main concern of conservative palliative treatment is the quality of life and the management of uremic symptoms, which have to be addressed by a multidisciplinary team.

Biomedicalization of end-of-life conversations with medically frail older adults - Malleable and senescent bodies

The common practice of delaying and/or avoiding end-of-life conversations with medically frail older adults is an important clinical issue. Most research investigating this practice focuses on clinician training and developing conversation skills. Little is known about the socio-political factors shaping the phenomenon of end-of-life conversations between clinicians and medically frail older patients. Using the critical lens of biomedicalization we consider how two dominant discourses, successful aging and frailty, and subsequent constructions of bodies as malleable or senescent, shape patient subjectivities and influence normative expectations about appropriate healthcare conversations and the consumption of biomedicine for medically frail adults. We highlight the uneven ways medically frail older adults are clinically positioned as successful or frail agers and briefly discuss how gender, class, and race may impact this tension and ambiguity. We conclude by arguing that end-of-life conversations with medically frail older adults is constrained by the pervasiveness of the successful aging discourse and the tendency within medical institutions to construct older bodies as malleable and in need of medical intervention to promote health and longevity.

Dialysis Regret: Prevalence and Correlates

BACKGROUND AND OBJECTIVES

Although some patients regret the decision to start dialysis, modifiable factors associated with regret have rarely been studied. We aimed to identify factors associated with patients' regret to initiate dialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A 41-item questionnaire was administered to adult patients receiving maintenance dialysis in seven dialysis units located in Cleveland, Ohio, and its suburbs. Of the 450 patients asked to participate in the study, 423 agreed and 397 provided data on decisional regret. We used multivariable logistic regression to identify predictors of regret, which was assessed using a single item, "Do you regret your decision to start dialysis?" We report adjusted odd ratios (ORs) and 95% confidence intervals (95% CIs) for the following candidate predictors: knowledge of CKD, attitudes toward CKD treatment, and preference for end-of-life care.

RESULTS

Eighty-two of 397 respondents (21%) reported decisional regret. There were no significant demographic correlates of regret. Regret was more common when patients reported choosing dialysis to please doctors or family members (OR, 2.34; 95% CI, 1.27 to 4.31; P<0.001). Patients who reported having a prognostic discussion about life expectancy with their doctors (OR, 0.42; 95% CI, 0.18 to 0.98; P=0.03) and those who had completed a living will (OR, 0.48; 95% CI, 0.25 to 0.95; P=0.03) were less likely to report regret with dialysis initiation.

CONCLUSIONS

Dialysis regret was common in this sample. Demographic factors (age, sex, marital status, race, or educational attainment) were not significantly associated with regret, but modifiable care processes were.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_06_09_CJN13781119.mp3.

Exploring the choices and outcomes of older patients with advanced kidney disease

A lack of data on patient choices and outcomes at the time of pre-dialysis planning limits meaningful shared decision making, particularly in older frailer patients. In this large retrospective cohort study of patients aged over 70 seen by the pre-dialysis clinic (2004–2016) of a large single centre in the United Kingdom (1,216 patients), age, sex, comorbidity, poverty and frailty were used to predict choice of renal replacement therapy (RRT) over maximum conservative management (MCM). The impact of patient choice of RRT versus MCM was used to predict survival from the time of choice using multivariable Cox proportional hazards regression. Older age, female sex, greater poverty and greater frailty were associated with choosing MCM, whilst comorbidity had no significant impact on choice. At 5 years of follow up, 49% of all patients had died without receiving RRT. Over 70% of the patients choosing MCM died with better kidney function than the median level at which those starting RRT initiated treatment. Frailty and age were better predictors of survival than comorbidity and in patients with at least moderate frailty, RRT offered no survival benefit over MCM. In conclusion, analysing outcomes from the time of choice may improve shared decision making. Frailty should be routinely assessed and collected and further work may help predict which patients are unlikely to survive or progress to end stage renal disease and may not need to be burdened with making a pre-dialysis choice.

Beliefs About Advanced Cancer Curability in Older Patients, Their Caregivers, and Oncologists

BACKGROUND

Ensuring older patients with advanced cancer and their oncologists have similar beliefs about curability is important. We investigated discordance in beliefs about curability in patient-oncologist and caregiver-oncologist dyads.

MATERIALS AND METHODS

We used baseline data from a cluster randomized trial assessing whether geriatric assessment improves communication and quality of life in older patients with advanced cancer and their caregivers. Patients were aged ≥70 years with incurable cancer from community oncology practices. Patients, caregivers, and oncologists were asked: "What do you believe are the chances the cancer will go away and never come back with treatment?" Options were 100%, >50%, 50/50, <50%, and 0% (5-point scale). Discordance in beliefs about curability was defined as any difference in scale scores (≥3 points were severe). We used multivariate logistic regressions to describe correlates of discordance.

RESULTS

Discordance was present in 60% (15% severe) of the 336 patient-oncologist dyads and 52% (16% severe) of the 245 caregiver-oncologist dyads. Discordance was less common in patient-oncologist dyads when oncologists practiced longer (adjusted odds ratio [AOR] 0.90, 95% confidence interval [CI] 0.84-0.97) and more common in non-Hispanic white patients (AOR 5.77, CI 1.90-17.50) and when patients had lung (AOR 1.95, CI 1.29-2.94) or gastrointestinal (AOR 1.55, CI 1.09-2.21) compared with breast cancer. Severe discordance was more common when patients were non-Hispanic white, had lower income, and had impaired social support. Caregiver-oncologist discordance was more common when caregivers were non-Hispanic white (AOR 3.32, CI 1.01-10.94) and reported lower physical health (AOR 0.88, CI 0.78-1.00). Severe discordance was more common when caregivers had lower income and lower anxiety level.

CONCLUSION

Discordance in beliefs about curability is common, occasionally severe, and correlated with patient, caregiver, and oncologist characteristics.

IMPLICATIONS FOR PRACTICE

Ensuring older patients with advanced cancer and their caregivers have similar beliefs about curability as the oncologist is important. This study investigated discordance in beliefs about curability in patient-oncologist (PO) and caregiver-oncologist (CO) dyads. It found that discordance was present in 60% (15% severe) of PO dyads and 52% (16% severe) of CO dyads, raising serious questions about the process by which patients consent to treatment. This study supports the need for interventions targeted at the oncologist, patient, caregiver, and societal levels to improve the delivery of prognostic information and patients'/caregivers' understanding and acceptance of prognosis.

Challenges in informed consent decision-making in Korean clinical research: A participant perspective

Objectives

This study investigated how the essential elements of informed consent are realised during the consent process and examined the challenges in obtaining genuine informed consent in Korea.

Methods

Through purposive sampling, we recruited 21 subjects from those participating in anticancer drug research since 2013. We undertook 1:1 in-depth interviews and analysed the data by framework analysis.

Results

Themes raised throughout the interviews were categorised into ‘disclosure’ and ‘understanding’ of clinical information and ‘decision’. Provider-centred information, both verbal and written, was delivered to each participant. There were few tools that the research staff might evaluate study participants’ level of understanding of the provided information during the clinical trial. Although participants did not understand basic clinical trial concepts as much as desired, they may not seek to solve difficulties through communication with trial researchers. Doubts were raised about whether participants had sufficient capacity and free will to provide informed consent.

Conclusion

There is a concern that informed consent can fall short of genuine in Korea. To ensure informed consent meets the international standard, greater efforts should be made to establish an explicit standard operational protocol for obtaining informed consent.

Unique palliative care needs of patients with advanced chronic kidney disease - the scope of the problem and several solutions

Patients with advanced chronic kidney disease (CKD), including end-stage renal disease (ESRD), have a life-threatening illness complicated by high morbidity and mortality and, therefore, should be suitable candidates for early intervention by palliative care specialists. However, the average patient with CKD does not have an advanced care plan, has multiple debilitating symptoms, and does not utilise hospice care at the end of life. In this review, we outline the scope of the problem of unmet palliative care needs for patients with advanced CKD and ESRD, barriers to improving palliative care for patients with renal failure, and possible future directions for palliative nephrology.

Dialysis versus Medical Management at Different Ages and Levels of Kidney Function in Veterans with Advanced CKD

Background Appropriate patient selection and optimal timing of dialysis initiation among older adults with advanced CKD are uncertain. We determined the association between dialysis versus medical management and survival at different ages and levels of kidney function.Methods We assembled a nationally representative 20% sample of United States veterans with eGFR<30 ml/min per 1.73 m² between 2005 and 2010 (n=73,349), with follow-up through 2012. We used an extended Cox model to determine associations among the time-varying exposures, age (<65, 65-74, 75-84, and ≥85 years), eGFR (<6, 6-<9, 9-<12, 12-<15, and 15-<29 ml/min per 1.73 m²), and provision of dialysis, and survival.Result Over the mean±SEM follow-up of 3.4±2.2 years, 15% of patients started dialysis and 52% died. The eGFR at which dialysis, compared with medical management, associated with lower mortality varied by age (P<0.001). For patients aged <65, 65-74, 75-84, and ≥85 years, dialysis associated with lower mortality for those with eGFR not exceeding 6-<9, <6, 9-<12, and 9-<12 ml/min per 1.73 m², respectively. Dialysis initiation at eGFR<6 ml/min per 1.73 m² associated with a higher median life expectancy of 26, 25, and 19 months for patients aged 65, 75, and 85 years, respectively. When dialysis was initiated at eGFR 9-<12 ml/min per 1.73 m², the estimated difference in median life expectancy was <1 year for these patients.Conclusions Provision of dialysis at higher levels of kidney function may extend survival for some older patients.