Modality selection for treatment of end stage kidney disease (ESKD) is a complex, life-changing decision that patients with chronic kidney disease (CKD) must address. Offering conservative, or non-dialysis therapy, as an option continues to be a challenge for nephrologists. Conversations to discuss this option are held infrequently, due to prognostic uncertainty, a lack of an organizational care framework, and significant emotional attachments (1, 2). In a recent article, Hamroun and colleagues (3) highlight another possible compelling reason: a disproportionate belief in physicians’ ability to communicate effectively with patients.
Physicians tend to overestimate their communication proficiency (4). Hamroun and colleagues (3) echo this concern in their article, specifically in the setting of discussing non-dialytic care for patients with advanced CKD. The investigators used data from the CKD-REIN (Renal Epidemiology and Information Network) cohort, which studied 38 nationally representative nephrology clinics in France. Surveys were collected from 137 nephrologists and 1206 patients with CKD stage 4 regarding treatment options for kidney failure. It was found that all participating clinics (100%) reported their ability to offer conservative care for their patients, with more than 70% of these centers routinely providing classes for patients to learn about options for their management. Furthermore, the majority of nephrologists (93%) reported they routinely discuss conservative management with their patients, with 81% of these physicians attesting they were at least fairly comfortable talking about the topic. Despite this, only 5% of surveyed patients reported that their doctor informed them that “no dialysis” was an option. Of the respondents who attended the educational sessions, only 10% claimed they received information about conservative management. There seems to be a marked discrepancy between nephrologists’ perceived ability to present information and patients’ accounts of the information they received. The consequence of this discrepancy is further accentuated by the low percentage of patients in the cohort (6%) who ultimately opted for conservative care.
Nephrologists may overestimate their success in having goals of care discussions with patients, as patients do not recall these conversations to the same extent, suggesting ineffective communication. A number of studies have glanced at this inconsistency between nephrologists’ reported experience and actual practice patterns through the lens of palliative care. Although most nephrologists reported the utmost confidence in their palliative care training, including integrating advance care planning discussions in their routine care of patients with CKD (5), the rate of hospice use for this population lags far behind that of patients with other terminal illnesses, such as cancer, dementia, or lung disease (6).
Hamroun and colleagues (3) cite reasons for this gap in communication, including the inconsistent decision-making styles that nephrologists were found to use to mitigate their own emotional burdens (1, 3) and the vague terminology to describe and advise conservative or palliative care (3). Table 1 outlines strategies to overcome various barriers to effective communication. Moreover, there is hope, according to Hamroun and colleagues (3), that future research can guide nephrologists to implement unfiltered communication strategies to help streamline conservative care information for ESKD patients.
Strategies to promote effective communication about conservative kidney health care
References
- 1.↑
Wachterman MW, et al. Nephrologists’ emotional burden regarding decision-making about dialysis initiation in older adults: A qualitative study. BMC Nephrol 2019; 20:385. doi: 10.1186/s12882-019-1565-x
- 2.↑
Nair D, et al. Barriers and facilitators to discussing goals of care among nephrology trainees: A qualitative analysis and novel educational intervention. J Palliat Med 2020; 23:1045–1051. doi: 10.1089/jpm.2019.0570
- 3.↑
Hamroun A, et al. Barriers to conservative care from patients’ and nephrologists’ perspectives: The CKD-REIN study. Nephrol Dial Transplant [published online ahead of print January 13, 2022]. doi: 10.1093/ndt/gfac009; https://academic.oup.com/ndt/advance-article-abstract/doi/10.1093/ndt/gfac009/6506464?redirectedFrom=fulltext&login=false
- 4.↑
Tongue JR, et al. Communication skills for patient-centered care: Research-based, easily learned techniques for medical interviews that benefit orthopaedic surgeons and their patients. J Bone Joint Surg Am 2005; 87:652–658. https://journals.lww.com/jbjsjournal/Citation/2005/03000/Communication_Skills_for_Patient_Centered_Care_.27.aspx
- 5.↑
Metzger M, et al. Nephrology and palliative care collaboration in the care of patients with advanced kidney disease: Results of a clinician survey. Kidney Med 2021; 3:368–377.e1. doi: 10.1016/j.xkme.2021.01.008
- 6.↑
Schwarze ML, et al. Hospice use and end-of-life care for patients with end-stage renal disease: Too little, too late. JAMA Intern Med 2018; 178:799–801. doi: 10.1001/jamainternmed.2018.1078
- 7.
Park EM, et al. An exploratory study of end-of-life prognostic communication needs as reported by widowed fathers due to cancer. Psychooncology 2015; 24:1471–1476. doi: 10.1002/pon.3757
- 8.
Brighton LJ, Bristowe K. Communication in palliative care: Talking about the end of life, before the end of life. Postgrad Med J 2016; 92:466–470. doi: 10.1136/postgradmedj-2015-133368
- 9.
Clayton JM, et al. Sustaining hope when communicating with terminally ill patients and their families: A systematic review. Psychooncology 2008; 17:641–659. doi: 10.1002/pon.1288
- 10.
Scherer JS, et al. A descriptive analysis of an ambulatory kidney palliative care program. J Palliat Med 2020; 23:259–263. doi: 10.1089/jpm.2018.0647
