Advance care plan barriers in older patients with end-stage renal disease: A qualitative nephrologist interview study

Julien O'Riordan*, Helen Noble, P. M. Kane, Andrew Smyth

*Corresponding author for this work

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Abstract

Objectives: Older patients with end-stage renal disease are willing participants in advance care planning but just over 10% are engaged in this process. Nephrologists fear such conversations may upset patients and so tend to avoid these discussions. This approach denies patients the opportunity to discuss their end-of-life care preferences. Many patients endure medically intensive end-of-life scenarios as a result. This study aims to explore the rationale underpinning nephrologists' clinical decision-making in the management of older patients with end-stage renal disease and to make recommendations that inform policymakers and enhance advance care planning for this patient group. Methods: A qualitative interview study of 20 nephrologists was undertaken. Nephrologists were asked about their management of end-stage renal disease in older patients, conservative management, dialysis withdrawal and end-of-life care. Eligible participants were nephrologists working in Ireland. Five nephrologists participated in a recorded focus group and 15 nephrologists participated in individual digitally recorded telephone interviews. Semistructured interviews were conducted; thematic analysis was used to distil the results. Results: Three key themes emerged: barriers to advance care planning; barriers to shared decision-making; and avoidance of end-of-life care discussion. Conclusions: Advance care planning is not an integral part of the routine care of older patients with end-stage renal disease. Absence of formal training of nephrologists in how to communicate with patients contributes to poor advance care planning. Nephrologists lack clinical experience of conservatively managing end-stage renal disease and end-of-life care in older patients. Key policy recommendations include formal communication skills training for nephrologists and development of the conservative management service.

Original languageEnglish
Number of pages8
JournalBMJ Supportive and Palliative Care
Early online date25 Jun 2019
DOIs
Publication statusEarly online date - 25 Jun 2019

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Keywords

  • advance care planning
  • conservative management
  • dialysis withdrawal
  • end-of-life care
  • end-stage renaldisease (ESRD)
  • qualitative

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