Effective communication is necessary when providing medical care but can prove challenging when attempting to match patients’ values to therapies. Nephrologists often participate in difficult conversations with patients and their families, most commonly involving dialysis in patients with chronic kidney disease (CKD) and ESRD. Despite this, most nephrologists and nephrology fellows do not feel prepared for these difficult conversations (1–3).
In recent years, there has been an increasing focus on goals of care and utilization of a palliative approach in advanced CKD and dialysis care. The aim is to address the symptoms, pain, and stress of advanced kidney disease to improve quality of life. To accomplish these goals, nephrology care providers need to discuss prognosis and goals of care with their patients. There are few specific resources available to help guide nephrologists in these difficult conversations. These include journal articles, a 4-hour communication skills workshop geared toward nephrology fellows (Nephrotalk), and the Renal Physicians Association Clinical Practice Guidelines on Shared Decision-Making in Dialysis & Toolkit (1–5).
Trainees and practicing nephrologists should increase their efforts to use the resources available to help them tackle these discussions with their patients. Although the tendency might be to avoid these conversations due to discomfort or fear of upsetting patients, it has been shown that the majority of patients find it important to be informed about their medical condition, including prognosis (6). As a result, building skills in having difficult discussions will not only improve physician comfort and create more effective communication for future interactions but also meet important patient needs. The techniques taught in the 4-hour workshop provide basic skills for these discussions, including assessing understanding, giving information, responding to emotion, and matching patient values to treatment options. When it comes to giving bad news or assessing goals of care, the physician should start with open-ended questions, use a communication framework, and use the individual skills where appropriate (2).
Davison SN, et al.. Nephrologists’ reported preparedness for end-of-life decision-making. Clin J Am Soc Nephrol 2006; 1:1256–1262.
Schell JO, et al.. Communication skills training for dialysis decision-making and end-of-life care in nephrology. Clin J Am Soc Nephrol 2013; 8:675–680.
O’Hare AM. Palliative and end-of-life care in patients with kidney disease. USRDS special study on palliative and end-of-life care. https://www.usrds.org/2014/pres/ASN_usrds_OHare_Presented.pdf.
Kurella Tamura M, Meier DE. Five policies to promote palliative care for patients with ESRD. Clin J Am Soc Nephrol 2013; 8:1783–1790.
Grubbs V, et al.. A palliative approach to dialysis care: a patient-centered transition to the end of life. Clin J Am Soc Nephrol 2014; 9:2203–2209.
Davison SN. End-of-life care preferences and needs: Perceptions of patients with chronic kidney disease. Clin J Am Soc Nephrol 2010; 5:195–204.
Carson RC, et al.. Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease? Clin J Am Soc Nephrol 2009; 4:1611–1619.
Murtagh FEM, et al.. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant 2007; 22:1955–1962.
Van den Bosch J, Warren DS, Rutherford PA. Review of predialysis education programs: A need for standardization. Patient Prefer Adherence 2015; 9:1279–1291.
Schmidt RJ, Moss AH. Dying on dialysis: The case for a dignified withdrawal. Clin J Am Soc Nephrol 2014; 9:174–180.