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Kidney Week

Abstract: SA-PO708

A Qualitative Analysis of the Medical Record of a National Cohort of Patients with Advanced Kidney Disease Not Treated with Maintenance Dialysis in the US Department of Veterans Affairs

Session Information

  • Geriatric Nephrology
    October 27, 2018 | Location: Exhibit Hall, San Diego Convention Center
    Abstract Time: 10:00 AM - 12:00 PM

Category: Geriatric Nephrology

  • 1100 Geriatric Nephrology

Authors

  • Wong, Susan P.Y., VA Health Services Research and Development Center, Seattle, Washington, United States
  • Mcfarland, Lynne V., Puget Sound VA, Seattle, Washington, United States
  • Liu, Chuan-fen, VA Puget Sound Health Care System, HSR&D, Seattle, Washington, United States
  • O'Hare, Ann M., VA Puget Sound Health Care System, Seattle, Washington, United States
Background

Although it is widely recognized that not all patients with advanced chronic kidney disease (CKD) will choose to receive maintenance dialysis, little is known about the clinical context in which these decisions occur.

Methods

We performed an in-depth qualitative analysis of the electronic medical records of a national cohort of 851 patients with advanced CKD and in whom there had been a decision not to initiate maintenance dialysis in the Veterans Affairs (VA) healthcare system between 2000-2011. We used inductive content analysis to identify clinical events, care processes, healthcare interactions and documented concerns of patients and providers relevant to the decision not to pursue dialysis

Results

Overall, 66.6% of cohort members were white and 61.3% were aged ≥75 years. We identified three major dynamics relevant to understanding the context in which decisions not to pursue dialysis unfolded: 1) Perseveration about dialysis, which reflected circumstances in which some patients had refused dialysis but providers did not readily accept this decision and seemed rooted to the possibility of starting dialysis. Providers repeatedly questioned patients’ preferences, questioned patients’ competency to make this decision, increased opportunities for patients to initiate dialysis, and proceeded as if patients would change their minds about dialysis; 2) Not candidates for dialysis, which reflected circumstances in which providers deemed some patients not to be candidates or appropriate for dialysis on the basis of patients’ characteristics and expected prognosis rather than on patients’ values and preferences; and, 3) Nothing left to offer, which reflected providers’ tendency to view that they had little else to offer when patients did not receive dialysis and pressed patients to enter hospice care, often before patients were ready.

Conclusion

Our findings reveal the all-or-nothing approach to caring for patients with advanced CKD who did not pursue maintenance dialysis. Greater efforts are needed to develop patient-centered models of care for advanced CKD capable of supporting those who do not to start dialysis.

Funding

  • NIDDK Support