A qualitative exploration of the factors that influence healthcare decision-making in the management of end stage renal disease in older adults in Ireland.
Date
2021-12-10Author
O'Riordan, Julien
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Abstract
Background
Older patients with end-stage renal disease (ESRD) are willing participants in advance care planning
(ACP) but just over 10% engage in it (1-3), potentially as nephrologists fear such conversations may
upset patients (4). Hence the values and wishes of patients are frequently underrepresented during
key healthcare decision-making (2, 5, 6).
Objectives
The objective of this thesis is to better understand the care of older patients requiring dialysis in
Ireland. First, to explore the approach of nephrologists to managing ESRD in these patients including
conservative management, dialysis withdrawal and end of life care. Second, to explore the
experience of these patients with dialysis, ACP and their satisfaction with life on dialysis.
Methods
Both studies utilised qualitative interviews and thematic analyses to distil the data addressing the
objectives.
Results
Twenty nephrologists working in Ireland and fifteen older dialysis patients participated respectively.
Nephrologists tend to avoid end of life care discussion reflecting limited communication skills
training, a fear of upsetting patients and time constraints. Additional barriers to ACP included limited
understanding of ESRD and dialysis by patients. Patients appeared disempowered, displayed limited
health literacy and well-being was compromised by limited ACP. Dialysis appeared to jeopardise
their core values.
Conclusion
The participation of nephrologists and older patients with ESRD in ACP and shared decision- making
in Ireland is suboptimal. Healthcare decision-making, including dialysis initiation, may not reflect
patients’ core values. Enhanced patient education and improved communication skills training for
clinicians to facilitate shared decision-making and ACP is recommended.