Conveying Uncertainty in Prognosis to Patients with ESRD

Abstract

Background: Prognosis is a component of medical practice imbued with uncertainty. In nephrology, where mortality rates of elderly patients on dialysis are comparable to those of cancer patients, the implications of prognosis are unavoidable. Yet while most patients with end-stage renal disease (ESRD) desire to hear their prognosis, many nephrologists balk at this prospect in part owing to the uncertainty inherent in prognostic estimates. Summary: In this review, the concept of ‘uncertainty' in clinical practice is considered from physician and patient perspectives. From the training perspective, providers learn that uncertainty is inescapable in medicine and develop strategies to manage its presence, including the avoidance of communicating uncertainty to their patients. This presages infrequent discussions of prognosis, which in turn influence patient preferences for treatments that have little therapeutic benefits. A general approach to conveying prognostic uncertainty to ESRD patients includes confronting our own emotional reaction to uncertainty, learning how to effectively communicate uncertainty to our patients, and using an effective interdisciplinary team approach to demonstrate an ongoing commitment to our patients despite the presence of prognostic uncertainty. Key Messages: Uncertainty in prognosis is inevitable. Once providers learn to incorporate it into their discussions of prognosis and collaborate with their ESRD patients, such discussions can foster trust and reduce anxiety for both sides.

Shared decision-making in end-stage renal disease: a protocol for a multi-center study of a communication intervention to improve end-of-life care for dialysis patients

“…The study is especially novel as it brings patients and stakeholders together with leading clinician-researchers who are interested in examining the integration of palliative medicine into the practice of nephrology. The primary investigators have previously conducted research involving severely ill and elderly ESRD patients [27–32]. The study’s interdisciplinary team contributes additional expertise in palliative care, communication, bioethics, psychiatry, and social work education [17, 33].…”

Discussions during shared decision-making in older adults with advanced renal disease: a scoping review

“…Physicians are uncomfortable about communicating prognosis to seriously ill patients 1 2. This is also true for nephrologists looking after patients with advanced kidney disease 3–7. There is evidence to suggest that patients receive insufficient information or are unrealistically optimistic about their prognosis 8 9.…”

Voices emerging from the shadows: Radiologic practitioners’ experiences of challenging conversations

“…Another challenge that emerged from the narratives was related to the communication and management of clinical uncertainty. The discussion of clinical uncertainty with patients has been identified as a difficult task across different clinical fields [34]. In the radiologic context, expectations may be unrealistically high for radiologic procedures and practitioners to provide immediate diagnostic certainty.…”

“…Clinicians can foster trust and reduce patient and staff anxiety when they confront their own emotional reaction to uncertainty, learn how to effectively communicate uncertainty to their patients, and use an effective interdisciplinary team approach [34].…”