Shared Decision-Making & Patient-Centered Care

I recently spoke with a loved one of patient in his mid-80s who is asymptomatic, with a GFR of 11 ml/min/1.73 m². The loved one described the patient as very alert (does the crossword puzzle daily), active and mobile (drives his car where he needs to go), with a good quality of life. The patient lives with and cares for a spouse with dementia and has two daughters who are close and happy to help with meals and medications. His potassium and phosphorus labs are within normal limits. The family has been touched by kidney failure before. A sibling 4 years younger has been on dialysis for several years and reportedly has a good quality of life.

Recently the caller accompanied the patient to a nephrologist appointment, and the doctor recommended that the patient choose conservative management instead of dialysis, explaining that research has found that elderly patients who do dialysis don’t live any longer than those who choose conservative management, and quality of life is better without treatment. The patient was disappointed. Did the nephrologist compare conservative management to all types of dialysis—or just to in-center HD, the default treatment? Had the nephrologist presented all of the options? When I asked the loved one if the nephrologist discussed peritoneal dialysis (PD) with the patient, the answer was no. It was clear that little was known about PD. The loved one was knowledgeable about HD, but didn’t know that the patient might be able to do PD alone if it was possible to learn sterile technique and do manual exchanges or operate a cycler, including troubleshooting alarms.

I share this story to encourage nephrologists and healthcare professionals who treat elderly patients to provide patient-centered care and make shared decisions by:

• Getting to know the patient as a person and individualize care rather than using a cookie cutter approach that often defaults to in-center HD.

• Providing fact-based education about all treatment options for which the patient might be a candidate – the MATCH-D tool can help clinicians review home dialysis candidacy.

• Encouraging the patient to review treatment options in light of their values, interests, lifestyle, and goals – My Dialysis Choice helps identify which treatment(s) fit best.

• Allowing (and encouraging) the patient to have an equal voice in decision-making.

It’s true that some 85-year old patients with late stage CKD are frail and have serious comorbid conditions, and poor mobility. Research has shown these to be risk factors for poor survival on dialysis.¹ Although many patients start dialysis when their GFR is higher, in compromised elderly patients, early start doesn’t improve survival chances.² Those patients may have a better quality of life with conservative management than with dialysis, especially in-center HD.

But other patients, like this one, should not be steered to forego dialysis without a comprehensive discussion of all appropriate options, including waiting to start until GFR has declined further. In fact, there is research that supports waiting to start dialysis in asymptomatic elderly patients until symptoms occur or GFR is ≤6 ml/min/1.73 m².³

PD may be an option for this patient as well. The International Society of Peritoneal Dialysis commissioned papers on managing elderly patients on PD. Among its many findings and recommendations were these:⁴

• Elderly patients had no worse catheter problems than younger patients, but HD accesses have more problems in older compared to younger patients.

• Survival is similar in elderly patients on PD and HD if the patient doesn’t have diabetes.

• An interdisciplinary team should assess elderly patients for PD and eligible patients should be offered PD.

• If there are barriers to PD in the elderly, often family, paid caregivers, and nursing home staff can overcome them.

• Clinics should individualize care and prescriptions to the patient’s wishes and expectations.

• Increasing the PD dose may not be appropriate if it will limit an elderly patient’s quality of life.

If a patient is interested in PD and can do it with or without family support, it might be best to wait until GFR is lower and symptoms adversely affect lifestyle. That could allow the patient to focus on living each day as fully as possible rather than waiting for death to occur. Waiting to start dialysis might mean death occurs from another cause before dialysis is needed. And even if the patient needs to start dialysis urgently, research has shown that starting dialysis on a cycler can be a safe and gentle option. If patient-centered care is more than a buzzword, don’t patients like this one deserve a full menu of treatment choices, which may or may not include no treatment?