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UrduAbstract: https://www.acpjournals.org/doi/10.7326/M22-1543
Editorial: https://www.acpjournals.org/doi/10.7326/M22-3431
URL goes live when the embargo lifts
Approximately 38 percent of adults aged 65 years or older have CKD. Older adults with advanced CKD face important, preference-sensitive decisions about kidney replacement therapy that are complicated by the uncertain timing of physical and kidney function decline. High-quality decision making is particularly important for older patients facing intensive lifelong therapies, such as dialysis, and requires that patients are knowledgeable about their prognosis and treatment options. However, patients are often underinformed about options for management of their condition, with fewer than 10 percent of dialysis patients discussing their prognosis with nephrologists, despite 90 percent wishing to do so.
Researchers from Tufts University randomly assigned 400 persons aged 70 years and older with nondialysis CKD stages 4 to 5 to DART or written education about treatment alone to assess whether the decision aid improved decisional quality compared with usual care. Participants were recruited from 8 nephrology clinics associated with 4 U.S. centers. The authors found that the use of DART improved decisional quality for 6 months, with modest attenuation at 18 months. They report that treatment preferences for participants changed from 50 percent “unsure” at baseline to 28, 20, and 14 percent at 18 months, respectively, with DART, versus 51 percent to 38, 35, and 18 percent with usual care. According to the authors, these findings underscore the promise of a replicable, scalable decision aid for preserving patient autonomy for critical decisions that determine how people live out their last stages of life.
An accompanying editorial from author at the University of Pittsburgh and University of Rochester call on clinicians to build an infrastructure and culture that supports shared decision making (SDM), a process that incorporates clinician and patient input and deliberation. They also advise that more nephrology programs provide formal education in communication skills and SDM competencies, clinicians develop better conservative kidney management (CKM) pathways for patients, and institutions address structural and financial barriers that discourage SDM and CKM.
