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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. 1Palliative Medicine, Galway University Hospitals, Galway, Ireland
  2. 2College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway, Ireland
  3. 3School of Nursing and Midwifery, Queen’s University Belfast, Belfast, UK
  4. 4Palliative Medicine, Specialist Community Palliative Care Services, Health Service Executive (HSE), Laois/ Offaly and Longford/ Westmeath, Ireland
  5. 5Clinical Research Facility, National University of Ireland, Galway, Ireland
  6. 6Nephrology, 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}gmail.com

Abstract

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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Footnotes

  • 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.

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