Challenges to Shared Decision Making About Treatment of Advanced CKD: A Qualitative Study of Patients and Clinicians

Enabling Patient Choice: The “Deciding Not to Decide” Option for Older Adults Facing Dialysis Decisions

“…2 This "choiceless choice" could lead them to acquiesce to unwanted vascular access surgery (as was the case with Mr. Johnson). 2,3,8 In one study of 3418 patients, 37% of patients aged $75 years who underwent a procedure for dialysis preparation died before dialysis initiation. 9 The DND approach represents an additional option to help patients maintain some control.…”

“…Nearly a decade ago, the American Society of Nephrology’s Choosing Wisely Campaign recommended shared decision making before dialysis initiation for older people with CKD. Yet decision making about RRT remains suboptimal, because genuine shared decision making is rarely incorporated 1 , 2 . Dialysis is often presented as the default option, 3 although Medicare data show that more than half of those >65.5 years initiating dialysis die within 12 months, 4 and dialysis confers limited survival advantage in older, frail people 5 …”

“…Both patients and nephrologists report being emotionally burdened by RRT decision making 2 , 6 . Many patients are ambivalent about their RRT choices, and want more time to finalize a decision 2 .…”

“…Both patients and nephrologists report being emotionally burdened by RRT decision making 2 , 6 . Many patients are ambivalent about their RRT choices, and want more time to finalize a decision 2 . Similarly, many nephrologists feel uncomfortable not offering dialysis for reasons that are poorly understood, but may include prognostic uncertainty and discomfort with death 6 , 7 .…”

The Elusive Promise of Shared Decision Making: A Step Forward

“…3 Although nephrologists are progressively being asked to engage in SDM, and professional nephrology societies have endorsed its use, 4,5 several challenges prevent widespread adoption and implementation. In this issue of AJKD, House et al 6 examine SDM experiences of nephrologists and older patients with advanced CKD facing treatment decisions.…”