Nephrologists’ Reported Preparedness for End-of-Life Decision-Making

Abstract

Nephrologists commonly engage in end-of-life decision-making with patients with ESRD and their families. The purpose of this study was to determine the perceived preparedness of nephrologists to make end-of-life decisions and to determine factors that are associated with the highest level of perceived preparedness. The nephrologist members of the Renal Physicians Association (RPA) and the Canadian Society of Nephrology were invited to participate in an online survey of their end-of-life decision-making practices. A total of 39% of 360 respondents perceived themselves as very well prepared to make end-of-life decisions. Age >46 yr, six or more patients withdrawn from dialysis in the preceding year, and awareness of the RPA/ American Society of Nephrology (ASN) guideline on dialysis decision-making were independently associated with the highest level of self-reported preparedness. Nephrologists who reported being very well prepared were more likely to use time-limited trials of dialysis and stop dialysis of a patient with permanent and severe dementia. Compared with Americans, Canadian nephrologists reported being equally prepared to make end-of-life decisions, stopped dialysis of a higher number of patients, referred fewer to hospice, and were more likely to stop dialysis of a patient with severe dementia. Nephrologists who have been in practice longer and are knowledgeable of the RPA/ASN guideline report greater preparedness to make end-of-life decisions and report doing so more often in accordance with guideline recommendations. To improve nephrologists' comfort with end-of-life decision-making, fellowship programs should teach the recommendations in the RPA/ASN guideline and position statement.

Dialysis in Late Life

“…Additional help for families and caregivers is often needed as they support their loved ones through the final stages of life. Younger nephrologists tend to express less self-assessed preparedness for discussions around end-of-life issues than those with longer experience (67). In addition, in a survey of nephrology fellows, although 99% identified that it was important to provide end-of-life care, they believed that they received the least education and felt least prepared to provide this type of care (68).…”

A Palliative Approach to Dialysis Care

“…For example, while patients with ESRD prefer to be given information about their prognosis by their physicians and those who participate in end-of-life discussions tend to prefer less aggressive care, few dialysis patients report having had even limited discussions about their wishes (28,(32)(33)(34). The dearth of discussions is likely fueled by provider uncertainty about prognosis and a lack of attention during training (35)(36)(37). However, reliable instruments have been developed to identify dialysis patients at highest risk of death, and fellowship training programs have been encouraged to attend more to building this skill (36,38,39).…”

The Ethics of Chronic Dialysis for the Older Patient

“…There are, however, several challenges to true informed consent and shared decision-making. First, nephrologists and nephrology fellows have reported that they feel ill-prepared to have these discussions (67,68). Second, physicians often bring their biases to the bedside, which can affect the patients' perception and ultimate decision (51,69).…”