BOSTON—Even though U.S. clinical practice guidelines generally recommend that nephrologists discuss all treatment options, including conservative management, with Stage 4 and 5 chronic kidney disease patients, that rarely occurs, according to a new study.

The report in BMC Nephrology points out that conservative management, an approach to treating end-stage kidney disease without dialysis, has advantages and disadvantages. Veterans Affairs Boston Healthcare System-led researchers note that the method is associated with fewer hospitalizations, better functional status and, potentially, better quality of life. On the other hand, it tends to lead to shorter life expectancy than treatment with dialysis.1

The report adds that conservative management is a well-established treatment approach in a number of Western countries, including the U.K. To find out why that is not the case in the United States, the study team explored U.S. nephrologists’ approaches to decision-making about dialysis and perspectives on conservative management among older adults.

For the qualitative research study, the authors interviewed 20 nephrologists—15 from academic centers and five from community practices—employing a semi-structured interview guide containing open-ended questions. Participants were 85% white, 75% male with mean age of 50.

“We found that decision-making about dialysis initiation in older adults can create emotional burden for nephrologists,” the study team writes. Researchers categorized nephrologist perspectives with four concepts:

  • Uncertainty exists about how a patient will do on dialysis,
  • The alternative to dialysis is death,
  • Confronting death is difficult, and
  • Patients do not regret initiating dialysis.

At the same time, three themes revealed different decision-making strategies that nephrologists use to reduce this emotional burden:

  • Convincing patients to “just do it” (i.e., dialysis),
  • Shifting the decision-making responsibility to patients, and
  • Utilizing time-limited trials of dialysis.

“A decision not to start dialysis and instead pursue conservative management can be emotionally burdensome for nephrologists for a number of reasons, including clinical uncertainty about prognosis on dialysis and discomfort with death,” the authors conclude. “Nephrologists’ attempts to reduce this burden may be reflected in different decision-making styles—paternalistic, informed, and shared decision-making. Shared decision-making may relieve some of the emotional burden while preserving patient-centered care.”

1.    Wachterman MW, Leveille T, Keating NL, Simon SR, Waikar SS, Bokhour B.Nephrologists’ emotional burden regarding decision-making about dialysisinitiation in older adults: a qualitative study. BMC Nephrol. 2019 Oct24;20(1):385. doi: 10.1186/s12882-019-1565-x. PubMed PMID: 31651262; PubMedCentral PMCID: PMC6814056.