Discussing Conservative Management With Older Patients With CKD: An Interview Study of Nephrologists

Abstract

Although dialysis may not provide a large survival benefit for older patients with kidney failure, few are informed about conservative management. Barriers and facilitators to discussions about conservative management and nephrologists' decisions to present the option of conservative management may vary within the nephrology provider community. Interview study of nephrologists. National sample of US nephrologists sampled based on sex, years in practice, practice type, and region. Qualitative semistructured interviews continued until thematic saturation. Thematic and narrative analysis of recorded and transcribed interviews. Among 35 semistructured interviews withnephrologists from 18 practices, 37% described routinely discussing conservative management ("early adopters"). 5 themes and related subthemes reflected issues that influence nephrologists' decisions to discuss conservative management andtheir approaches to these discussions: struggling todefine nephrologists' roles (determining treatment, instilling hope, and improving patient symptoms), circumventing end-of-life conversations (contending with prognostic uncertainty, fearing emotional backlash, jeopardizing relationships, andtailoring information), confronting institutional barriers (timeconstraints, care coordination, incentives fordialysis, and discomfort with variedconservative management approaches), conservative management as "no care," and moral distress. Nephrologists' approaches to conservative management discussions were shaped by perceptions of their roles and by a common view ofconservative management as no care. Their willingness to pursue conservative management was influenced by provider- and institutional-level barriers and experiences with older patients who regretted or had been harmed by dialysis (moral distress). Early adopters routinely discussed conservative management asa way of relieving moral distress, whereas others who were more selective in discussing conservative management experienced greater distress. Participants' views are likely mosttransferable to large academic medical centers, due to oversampling of academic clinicians. Our findings clarify how moral distress serves as a catalyst for conservative management discussion and highlight points of intervention and mechanisms potentially underlying low conservative management use in the United States.