Palliative and End-of-Life Care in Nephrology

Moving From Observations to Interventions

Nwamaka D. Eneanya; Michael K. Paasche-Orlow; Angelo Volandes


Curr Opin Nephrol Hypertens. 2017;26(4):327-334. 

In This Article

Dialysis Decision-making

Shared decision-making occurs when patients engage with their families and clinicians to understand their disease or condition, as well as the benefits, risks, limitations, alternatives and uncertainties of treatments before making an informed decision.[15,16] These conversations also include eliciting patients' values and preferences to facilitate optimal decision-making. However, studies about dialysis decision-making among patients with advanced CKD and ESRD have been limited.[3,17] One study featuring the qualitative analysis of electronic medical records in a national cohort of ESRD patients showed significant heterogeneity in clinician practice patterns and attitudes.[18] Many of the nephrologists' clinical notes reflected a paternalistic style of practice and an emphasis on the biological benefits of dialysis (e.g. clinical laboratories and symptoms of uremia) as opposed to patient preferences, values and experience. In fact, far from shared decision-making, this analysis revealed clinical norms that accepted initiation of dialysis despite direct resistance from patients. Given these findings, the integration of palliative care practitioners who are committed to shared decision-making into the dialysis treatment decision-making process or palliative care and shared decision-making training for nephrologists, may be central to supporting patients and their families given the complexity of these decisions.[19] Cohen et al.[20] recently implemented an educational programme among nephrology trainees to improve several aspects of palliative care delivery including effectively discussing disease progression, prognostic uncertainty and dialysis decision-making After completing a 1-day workshop, trainees reported an increase in their patient communication skills as well as having more confidence in dealing with clinical ambiguity. Interventions such as these will likely be part of an overall effort to shift the culture of clinical nephrology toward educating and activating patients and their clinicians for shared decision-making. As the development of decision support strategies has become a high research priority in palliative care, future interventions should also focus on the effect of palliative care education and services on more traditional decision-making outcomes such as decisional conflict, regret and confidence with regard to ESRD treatment decisions.[21] Early interventions may particularly be useful in guiding the decision-making process for patients and their families in which the benefits of dialysis therapies are unclear. In these circumstances, patients' preferences and values can be incorporated earlier in the course of the illness and clinicians may find more opportunities to provide better decision support.[22]