The Shared Decision-Making Process as the Recommended Standard for Treatment Decisions in Kidney Disease and Requisite Communication Skills to Implement the Process

Abstract

Shared decision-making (SDM) is the accepted standard of care paradigm for medical decision making between patient or surrogate and clinician. In its Choosing Wisely campaign, the American Society of Nephrology (ASN) recommended SDM prior to the initiation of dialysis. Evidence suggests that SDM enhances patients’ understanding of their illness and satisfaction with the decision-making process, but at present SDM is poorly integrated into dialysis decision-making. Dialysis patients often describe a passive role in the decision to start dialysis, reinforcing the need for implementation of SDM in decision-making with patients with kidney disease. The hallmark feature of SDM is collaboration between the clinician and the patient or surrogate whereby the patient’s expertise in the realm of values and priorities is elicited while the clinician’s medical expertise is shared. The ultimate treatment decision results from the integration of their respective expertise. The Agency for Healthcare Research and Quality SHARE Approach outlines the components of SDM, and frameworks such as the Serious Illness Conversation Guide, REMAP, and SPIRES are roadmaps for those components. Communication tools and mnemonics also facilitate SDM conversations. With knowledge and application of these frameworks and tools, the nephrology community will be better positioned to fulfill the mandate embodied in the ASN Choosing Wisely campaign to employ the SDM process in renal replacement therapy decisions.