Factors influencing patient choice of dialysis versus conservative care to treat end-stage kidney disease

Morton, Rachael L.; Snelling, Paul; Webster, Angela C; Rose, John M.; Masterson, Rosemary; Johnson, David W.; Howard, Kirsten

doi:10.1503/cmaj.111355

Cited by 172 publications

(146 citation statements)

References 27 publications

(40 reference statements)

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“…Starting dialysis was associated with a substantial and sustained decline in functional status among nursing home residents (3), and RRT may not be beneficial in the context of increasing frailty and loss of independence (4)(5)(6). A conservative care pathway is increasingly recognized as an alternative treatment to dialysis and has been introduced in the United Kingdom (UK) (1,(6)(7)(8)(9)(10), Australia (11,12), other European countries (13)(14)(15), and Asia (16)(17)(18).…”

Section: Introductionmentioning

confidence: 99%

Conservative Care for ESRD in the United Kingdom

Okamoto

Tonkin‐Crine

Rayner

et al. 2015

Clinical Journal of the American Society of Nephrology

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Background and objectives Conservative kidney management (CKM) has been developed in the United Kingdom (UK) as an alternative to dialysis for older patients with stage 5 CKD (CKD5) and multiple comorbidities. This national survey sought to describe the current scale and pattern of delivery of conservative care in UK renal units and identify their priorities for its future development.Design, setting, participants, & measurements A survey on practice patterns of CKM for patients age 75 and older with CKD5 was sent to clinical directors of all 71 adult renal units in the UK in March 2013.Results Sixty-seven units (94%) responded. All but one unit reported providing CKM for some patients. Terminology varied, although "conservative management" was the most frequently used term (46%). Lack of an agreed-upon definition of when a patient is receiving CKM made it difficult to obtain meaningful data on the numbers of such patients. Fifty-two percent provided the number of CKM patients age $75 years in 2012; the median was 45 per unit (interquartile range [IQR], 20-83). The median number of symptomatic CKM patients who would otherwise have started dialysis was eight (IQR,. CKM practice patterns varied: 35% had a written guideline, 23% had dedicated CKM clinics, 45% had dedicated staff, and 50% provided staff training on CKM. Most units (88%) provided primary care clinicians with information/advice regarding CKM. Eighty percent identified a need for better evidence comparing outcomes on CKM versus dialysis, and 65% considered it appropriate to enter patients into a randomized trial.Conclusions CKM is provided in almost all UK renal units, but scale and organization vary widely. Lack of common terminology and definitions hinders the development and assessment of CKM. Many survey respondents expressed support for further research comparing outcomes with conservative care versus dialysis.

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Section: Introductionmentioning

confidence: 99%

Conservative Care for ESRD in the United Kingdom

Okamoto

Tonkin‐Crine

Rayner

et al. 2015

Clinical Journal of the American Society of Nephrology

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“…Patients, when they are aware of a short prognosis, are more likely to focus on supportive treatment than life extension (12). Using a discrete choice study design, Morton et al (13) have shown that patients are willing to forgo up to 7 months of life expectancy on dialysis to reduce hospital visits and up to 15 months to be able to travel.…”

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confidence: 99%

Mortality in the Elderly on Dialysis

Iyasere

Brown

2015

Clinical Journal of the American Society of Nephrology

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“…In a third study of 105 patients with CKD, many were willing to make substantial tradeoffs in survival (up to 15 months) in exchange for improved quality of life. Some viewed time spent on dialysis and restrictions on travel imposed by dialysis treatments as detrimental to their quality of life, and said they would be willing to accept shorter survival in order to reduce treatment time and travel restrictions (9).…”

Section: History and Growth Of The Medicare Esrd Programmentioning

confidence: 99%

“…Studies of dialysis patients' preferences for end-of-life care suggest that much of the high-intensity, high-cost care currently delivered to older patients with advanced kidney disease may be unwanted, and that efforts to align treatment decisions with what matters most to individual patients may lead many patients to choose lower-intensity, lower-cost treatments (7)(8)(9). Experience in oncology reveals that efforts to align treatment plans with patient preferences and to integrate palliative care earlier in the course of illness are shown to result in better patient quality of life, less aggressive care, earlier referral to hospice, better caregiver bereavement adjustment, and lower costs (10)(11)(12)(13).…”

Section: Introductionmentioning

confidence: 99%

Patient-Centered Care

O’Hare

Armistead²,

Schrag

et al. 2014

Clinical Journal of the American Society of Nephrology

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In light of mounting federal government debt and levels of Medicare spending that are widely viewed as unsustainable, commentators have called for a transformation of the United States health care system to deliver better care at lower costs. This article presents the priorities of the Coalition for Supportive Care of Kidney Patients for how clinicians might achieve this transformation for patients with advanced CKD and their families. The authors suspect that much of the high-intensity, high-cost care currently delivered to patients with advanced kidney disease may be unwanted and that the "Three Aims" put forth by the National Quality Strategy of better care for the individual, better health for populations, and reduced health care costs may be within reach for patients with CKD and ESRD. This work describes the coalition's vision for a more patient-centered approach to the care of patients with kidney disease and argues for more concerted efforts to align their treatments with their goals, values, and preferences. Key priorities to achieve this vision include using improved prognostic models and decision science to help patients, their families, and their providers better understand what to expect in the future; engaging patients and their families in shared decision-making before the initiation of dialysis and during the course of dialysis treatment; and tailoring treatment strategies throughout the continuum of their care to address what matters most to individual patients.

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Factors influencing patient choice of dialysis versus conservative care to treat end-stage kidney disease

Cited by 172 publications

References 27 publications

Conservative Care for ESRD in the United Kingdom

Conservative Care for ESRD in the United Kingdom

Mortality in the Elderly on Dialysis

Patient-Centered Care

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