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Advance care plan barriers in older patients with end-stage renal disease: a qualitative nephrologist interview study
  1. Julien O'Riordan1,2,
  2. Helen Noble3,
  3. P M Kane4 and
  4. Andrew Smyth5,6
  1. 1 Palliative Medicine, Galway University Hospitals, Galway, Ireland
  2. 2 College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway, Ireland
  3. 3 School of Nursing and Midwifery, Queen’s University Belfast, Belfast, UK
  4. 4 Palliative Medicine, Specialist Community Palliative Care Services, Health Service Executive (HSE), Laois/ Offaly and Longford/ Westmeath, Ireland
  5. 5 Clinical Research Facility, National University of Ireland, Galway, Ireland
  6. 6 Nephrology, Galway University Hospitals, Galway, Ireland
  1. Correspondence to Dr Julien O'Riordan, Palliative Medicine Department, Galway University Hospitals, Galway H91 YR71, Ireland; julien.oriordan{at}


Objectives Older patients with end-stage renal disease are willing participants in advance care planning but just over 10% are engaged in this process. Nephrologists fear such conversations may upset patients and so tend to avoid these discussions. This approach denies patients the opportunity to discuss their end-of-life care preferences. Many patients endure medically intensive end-of-life scenarios as a result. This study aims to explore the rationale underpinning nephrologists’ clinical decision-making in the management of older patients with end-stage renal disease and to make recommendations that inform policymakers and enhance advance care planning for this patient group.

Methods A qualitative interview study of 20 nephrologists was undertaken. Nephrologists were asked about their management of end-stage renal disease in older patients, conservative management, dialysis withdrawal and end-of-life care. Eligible participants were nephrologists working in Ireland. Five nephrologists participated in a recorded focus group and 15 nephrologists participated in individual digitally recorded telephone interviews. Semistructured interviews were conducted; thematic analysis was used to distil the results.

Results Three key themes emerged: barriers to advance care planning; barriers to shared decision-making; and avoidance of end-of-life care discussion.

Conclusions Advance care planning is not an integral part of the routine care of older patients with end-stage renal disease. Absence of formal training of nephrologists in how to communicate with patients contributes to poor advance care planning. Nephrologists lack clinical experience of conservatively managing end-stage renal disease and end-of-life care in older patients. Key policy recommendations include formal communication skills training for nephrologists and development of the conservative management service.

  • advance care planning
  • end-stage renaldisease (ESRD)
  • conservative management
  • dialysis withdrawal
  • end-of-life care
  • qualitative

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  • Contributors All authors contributed to the research process.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethical approval was obtained. (Ref: CA 1734).

  • Provenance and peer review Not commissioned; externally peer reviewed.