PT - JOURNAL ARTICLE AU - Julien O'Riordan AU - Helen Noble AU - P M Kane AU - Andrew Smyth TI - Advance care plan barriers in older patients with end-stage renal disease: a qualitative nephrologist interview study AID - 10.1136/bmjspcare-2018-001759 DP - 2020 Dec 01 TA - BMJ Supportive & Palliative Care PG - e39--e39 VI - 10 IP - 4 4099 - http://spcare.bmj.com/content/10/4/e39.short 4100 - http://spcare.bmj.com/content/10/4/e39.full SO - BMJ Support Palliat Care2020 Dec 01; 10 AB - 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.