Time to Improve Informed Consent for Dialysis: An International Perspective

Brennan, Frank; Stewart, Cameron; Burgess, Hannah; Davison, Sara N.; Moss, Alvin H.; Murtagh, Fliss E.M.; Germain, Michael J.; Tranter, Shelley; Brown, Mark

doi:10.2215/cjn.09740916

Cited by 39 publications

(45 citation statements)

References 31 publications

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“…Multimodal interventions are needed to improve how oncologists communicate prognosis and to empower older patients and their caregivers to enquire about prognosis, taking into account the racial, cultural, and socioeconomic backgrounds of the patients and caregivers as well as their beliefs, emotions, and fears . In addition, the problem of severe discordance may require broader public health and policy initiatives to assess whether patients are adequately informed to provide consent to potentially toxic treatments . Nonetheless, although avoiding discordance would seem to be clinically intuitive, it is important to note that, unlike patient's perceived prognosis and curability, the association of discordance in beliefs about curability with outcomes is not well studied, and future studies are needed to assess its relationship with outcomes.…”

Section: Discussionmentioning

confidence: 99%

Beliefs About Advanced Cancer Curability in Older Patients, Their Caregivers, and Oncologists

et al. 2019

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Background Ensuring older patients with advanced cancer and their oncologists have similar beliefs about curability is important. We investigated discordance in beliefs about curability in patient‐oncologist and caregiver‐oncologist dyads. Materials and Methods We used baseline data from a cluster randomized trial assessing whether geriatric assessment improves communication and quality of life in older patients with advanced cancer and their caregivers. Patients were aged ≥70 years with incurable cancer from community oncology practices. Patients, caregivers, and oncologists were asked: “What do you believe are the chances the cancer will go away and never come back with treatment?” Options were 100%, >50%, 50/50, <50%, and 0% (5‐point scale). Discordance in beliefs about curability was defined as any difference in scale scores (≥3 points were severe). We used multivariate logistic regressions to describe correlates of discordance. Results Discordance was present in 60% (15% severe) of the 336 patient‐oncologist dyads and 52% (16% severe) of the 245 caregiver‐oncologist dyads. Discordance was less common in patient‐oncologist dyads when oncologists practiced longer (adjusted odds ratio [AOR] 0.90, 95% confidence interval [CI] 0.84–0.97) and more common in non‐Hispanic white patients (AOR 5.77, CI 1.90–17.50) and when patients had lung (AOR 1.95, CI 1.29–2.94) or gastrointestinal (AOR 1.55, CI 1.09–2.21) compared with breast cancer. Severe discordance was more common when patients were non‐Hispanic white, had lower income, and had impaired social support. Caregiver‐oncologist discordance was more common when caregivers were non‐Hispanic white (AOR 3.32, CI 1.01–10.94) and reported lower physical health (AOR 0.88, CI 0.78–1.00). Severe discordance was more common when caregivers had lower income and lower anxiety level. Conclusion Discordance in beliefs about curability is common, occasionally severe, and correlated with patient, caregiver, and oncologist characteristics. Implications for Practice Ensuring older patients with advanced cancer and their caregivers have similar beliefs about curability as the oncologist is important. This study investigated discordance in beliefs about curability in patient‐oncologist (PO) and caregiver‐oncologist (CO) dyads. It found that discordance was present in 60% (15% severe) of PO dyads and 52% (16% severe) of CO dyads, raising serious questions about the process by which patients consent to treatment. This study supports the need for interventions targeted at the oncologist, patient, caregiver, and societal levels to improve the delivery of prognostic information and patients’/caregivers’ understanding and acceptance of prognosis.

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Section: Discussionmentioning

confidence: 99%

Beliefs About Advanced Cancer Curability in Older Patients, Their Caregivers, and Oncologists

et al. 2019

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“…Patient surveys suggest the quality of dialysis decision making is often poor and may not meet the standard for informed consent in some circumstances. 22,23 Few patients receive prognostic information or have their preferences elicited, and many are not presented with the option to forgo dialysis. 24,25 Decision aids that incorporate prognostic information along with other expected outcomes could improve the quality of dialysis decision making and reduce variation in dialysis initiation practices.…”

Section: Discussionmentioning

confidence: 99%

Dialysis versus Medical Management at Different Ages and Levels of Kidney Function in Veterans with Advanced CKD

Tamura

Desai

Kapphahn

et al. 2018

JASN

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Appropriate patient selection and optimal timing of dialysis initiation among older adults with advanced CKD are uncertain. We determined the association between dialysis versus medical management and survival at different ages and levels of kidney function. We assembled a nationally representative 20% sample of United States veterans with eGFR<30 ml/min per 1.73 m between 2005 and 2010 (=73,349), with follow-up through 2012. We used an extended Cox model to determine associations among the time-varying exposures, age (<65, 65-74, 75-84, and ≥85 years), eGFR (<6, 6-<9, 9-<12, 12-<15, and 15-<29 ml/min per 1.73 m), and provision of dialysis, and survival. Over the mean±SEM follow-up of 3.4±2.2 years, 15% of patients started dialysis and 52% died. The eGFR at which dialysis, compared with medical management, associated with lower mortality varied by age (<0.001). For patients aged <65, 65-74, 75-84, and ≥85 years, dialysis associated with lower mortality for those with eGFR not exceeding 6-<9, <6, 9-<12, and 9-<12 ml/min per 1.73 m, respectively. Dialysis initiation at eGFR<6 ml/min per 1.73 m associated with a higher median life expectancy of 26, 25, and 19 months for patients aged 65, 75, and 85 years, respectively. When dialysis was initiated at eGFR 9-<12 ml/min per 1.73 m, the estimated difference in median life expectancy was <1 year for these patients. Provision of dialysis at higher levels of kidney function may extend survival for some older patients.

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“…Patients with ESRD do not often have conversations about their prognosis and all of their care options, including conservative, non-dialytic care. 17 There are several barriers to providing palliative care for patients with renal disease. Improving the integration of palliative care and nephrology by increased use of outpatient combined care models and improving training in palliative care for practicing nephrologists and trainees are several possible solutions to this pressing and multifaceted problem.…”

Section: Discussionmentioning

confidence: 99%

“…In a Boston study of patients on dialysis, no patients reported having a discussion of prognosis and, in 60% of cases, the nephrologist stated that they would not have provided a prognosis. 17 In 2014, Bristowe et al sought to establish a training program for nephrologists in ACP. In the preliminary data they collected on patient experience, the investigators identified that only 50% of patients felt that their concerns were taken seriously by their nephrologist, and less than half of patients felt that they had been sufficiently involved in treatment decisions.…”

Section: Developing a New Model Of Palliative Nephrologymentioning

confidence: 99%

Unique palliative care needs of patients with advanced chronic kidney disease – the scope of the problem and several solutions

Sturgill

Bear

2019

Clinical Medicine

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Patients with advanced chronic kidney disease (CKD), including end-stage renal disease (ESRD), have a lifethreatening illness complicated by high morbidity and mortality and, therefore, should be suitable candidates for early intervention by palliative care specialists. However, the average patient with CKD does not have an advanced care plan, has multiple debilitating symptoms, and does not utilise hospice care at the end of life. In this review, we outline the scope of the problem of unmet palliative care needs for patients with advanced CKD and ESRD, barriers to improving palliative care for patients with renal failure, and possible future directions for palliative nephrology.

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Time to Improve Informed Consent for Dialysis: An International Perspective

Cited by 39 publications

References 31 publications

Beliefs About Advanced Cancer Curability in Older Patients, Their Caregivers, and Oncologists

Beliefs About Advanced Cancer Curability in Older Patients, Their Caregivers, and Oncologists

Dialysis versus Medical Management at Different Ages and Levels of Kidney Function in Veterans with Advanced CKD

Unique palliative care needs of patients with advanced chronic kidney disease – the scope of the problem and several solutions

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