Abstract
To ensure that decisions to start and stop dialysis in ESRD are shared, the factors that affect patients and health care professionals in making such decisions must be understood. This systematic review sought to explore how and why different factors mediate the choices about dialysis treatment. MEDLINE, Embase, CINAHL, and PsychINFO were searched for qualitative studies of factors that affect patients' or health care professionals' decisions to commence or withdraw from dialysis. A thematic synthesis was conducted. Of 494 articles screened, 12 studies (conducted from 1985 to 2014) were included. These involved 206 patients (most receiving hemodialysis) and 64 health care professionals (age ranges: patients, 26-93 years; professionals, 26-61 years). For commencing dialysis, patients based their choice on "gut instinct," as well as deliberating over the effect of treatment on quality of life and survival. How individuals coped with decision-making was influential: Some tried to take control of the problem of progressive renal failure, whereas others focused on controlling their emotions. Health care professionals weighed biomedical factors and were led by an instinct to prolong life. Both patients and health care professionals described feeling powerless. With regard to dialysis withdrawal, only after prolonged periods on dialysis were the realities of life on dialysis fully appreciated and past choices questioned. By this stage, however, patients were physically dependent on treatment. As was seen with commencing dialysis, individuals coped with treatment withdrawal in a problem- or emotion-controlling way. Families struggled to differentiate between choosing versus allowing death. Health care teams avoided and queried discussions regarding dialysis withdrawal. Patients, however, missed the dialogue they experienced during predialysis education. Decision-making in ESRD is complex and dynamic and evolves over time and toward death. The factors at work are multifaceted and operate differently for patients and health professionals. More training and research on open communication and shared decision-making are needed.
Highlights
Dialysis brings high treatment burden to patients and families, considerable costs to health services, and high mortality
Over three quarters of those with ESRD are treated with dialysis (2); decisions on whether to start, continue, or stop dialysis remain poorly informed by evidence and rely predominantly on observational studies, with all their inherent limitations (3–5)
Families, and health care professionals make joint decisions about dialysis treatment, clinical practice guidelines were developed by the Renal Physicians Association (RPA) for shared decisionmaking in the appropriate initiation of and withdrawal from dialysis (6)
Summary
2 discourses identified: (1) The health care team’s power and dominance and (2) the patient’s struggle for shared decision making. The elderly patient’s right to participate in dialysis treatment did not seem to be well incorporated into the social practices of the unit. To explore the experiences of adults with potentially lifethreatening conditions in their decisions regarding treatment options; included cardiac, cancer and renal conditions. Experience level: Physicians, 17–30 yr; nurses, 4–30 yr n=18 renal health professionals, 43 dialysis patients Patients and health professionals: Age: 70–93 yr Sex: Not reported Ethnicity: Diverse Education level: Not reported n=18 patients recruited, 9 of whom had renal failure. Patients: Age: Range, 26–81 yr Sex: 9 women/9 men Ethnicity: 15 white, 2 black, 1 Native American Education level: Not recorded
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callMore From: Clinical Journal of the American Society of Nephrology
Disclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
