Discussing Conservative Management With Older Patients With CKD: An Interview Study of Nephrologists

Abstract

Background: Although dialysis may not provide a large survival benefit for older patients with kidney failure, few are informed about conservative management. Barriers and facilitators to discussions about conservative management and nephrologists' decisions to present the option of conservative management may vary within the nephrology provider community.

Study design: Interview study of nephrologists.

Setting & participants: National sample of US nephrologists sampled based on sex, years in practice, practice type, and region.

Methodology: Qualitative semistructured interviews continued until thematic saturation.

Analytical approach: Thematic and narrative analysis of recorded and transcribed interviews.

Results: Among 35 semistructured interviews with nephrologists from 18 practices, 37% described routinely discussing conservative management ("early adopters"). 5 themes and related subthemes reflected issues that influence nephrologists' decisions to discuss conservative management and their approaches to these discussions: struggling to define nephrologists' roles (determining treatment, instilling hope, and improving patient symptoms), circumventing end-of-life conversations (contending with prognostic uncertainty, fearing emotional backlash, jeopardizing relationships, and tailoring information), confronting institutional barriers (time constraints, care coordination, incentives for dialysis, and discomfort with varied conservative management approaches), conservative management as "no care," and moral distress. Nephrologists' approaches to conservative management discussions were shaped by perceptions of their roles and by a common view of conservative management as no care. Their willingness to pursue conservative management was influenced by provider- and institutional-level barriers and experiences with older patients who regretted or had been harmed by dialysis (moral distress). Early adopters routinely discussed conservative management as a way of relieving moral distress, whereas others who were more selective in discussing conservative management experienced greater distress.

Limitations: Participants' views are likely most transferable to large academic medical centers, due to oversampling of academic clinicians.

Conclusions: Our findings clarify how moral distress serves as a catalyst for conservative management discussion and highlight points of intervention and mechanisms potentially underlying low conservative management use in the United States.

Keywords: Geriatric nephrology; advanced CKD; chronic kidney disease (CKD); conservative management; dialysis; elderly; end-of-life planning; palliative care; patient-centered outcomes; qualitatitive study; qualitative methods; quality of life; semi-structured interviews; shared decision-making.

Figure 1. Factors influencing nephrologists’ decisions to discuss conservative management (CM)

This figure presents the spectrum of integration of CM into care discussions, spanning from no integration of CM to routine integration of CM. The boxes in the figure are derived from the thematic analysis, and convey barriers and facilitators affecting nephrologists’ decision to present CM, and factors affecting how they approach care discussions.