Shared Decision Making for Older Adults: Time to Move Beyond Dialysis as a Default

For older adults facing kidney therapy decisions, more dialysis is not always better. Currently, dialysis is often the default option, even for older patients with end-stage kidney disease (1). Yet, older people with several comorbidities tend to incur substantial burdens due to dialysis, including loss of independence and increased hospitalizations, at times without a significant survival benefit. Data suggest that many people make life-altering decisions for dialysis without receiving full information about their choices or discussing their prognosis (2). Alternative treatment options exist for individuals with kidney disease, especially for those who are likely to incur more burdens than benefits from dialysis. Conservative kidney management (CKM) is a nondialytic treatment option that focuses on symptom management and quality of life. Although many older people with advanced kidney disease express goals that align with comfort-based options such as CKM, most patients remain uninformed about CKM as a treatment choice (3). Even when patients express a wish to forego dialysis, data suggest that they often face resistance from nephrologists and providers who generally promote dialysis (1). Improving shared decision making (SDM), a process that incorporates clinician and patient input and deliberation, for these vital kidney therapy decisions is imperative (4). In their article, Ladin et al report one of the first large, multicenter, adequately powered randomized clinical trials that developed and examined the effectiveness of a literacy-sensitive online interactive decision aid for older adults over age 70 years (5). Patient decision aids (PDAs) have been shown to enhance SDM by improving patients' knowledge of available treatment choices. The investigators enrolled 400 patients with chronic kidney disease stages 4 to 5 and randomly assigned 183 patients to the intervention group and 180 to the control group. The intervention group interacted with the online DART (Decision-Aid for Renal Therapy), which provided information about kidney therapy options and general prognostic estimates, and helped patients explore their values. The DART decision aid responds to a clear need for better, balanced patient education for kidney treatment options. Existing kidney therapy PDAs are largely dialysisfocused and do not address the needs of older patients. Many do not present CKM as an option, few are literacy sensitive, and many ignore vision difficulties, readability challenges, and short attention spans (6). In addition, forprofit dialysis organizations who derive revenue from dialysis often provide kidney therapy education for many nephrology practices, raising ethical concerns. The primary outcome in the DART trial was a change in the decisional conflict scale (DCS) from baseline to 3, 6, 12, and 18months. The DCS has been used to evaluate the process of decision making: whether a treatment choice is felt to be informed, consistent with patient goals, and likely to be implemented. The investigators found a significant improvement in DCS scores at 3 and 6 months but not at 12 and 18 months. Significant improvements in knowledge scores at 3 and 6 months were also noted. Importantly, the proportion of people who were unsure about their choice was significantly lower in the intervention group, but the proportion of people choosing CKM rose from 11% at baseline to 17% at month 3 and 20% at month 6. Participants were mostly White with a low proportion of Black and Latinx patients. Non–English-speaking patients were excluded from the study (5). The results of DART PDA are promising, but we must not stop at PDAs and patient support tools to improve kidney decision making for older patients. To move beyond dialysis as a default option, it is important to build an infrastructure and culture that support SDM. First, nephrology clinicians must feel comfortable and sufficiently skilled to effectively engage in treatment decision conversations guided by patient goals. Currently, nephrology fellowship training and clinical practices are mostly built around dialysis with rare formal training in sharing person-centered kidney options such as CKM. Only a few nephrology programs provide formal education in communication skills and SDM competencies. Communication and SDM skills training programs for fellows, practicing nephrologists, and dialysis educators would promote crucial conversations and deliberation essential to guide kidney treatment decisions informed by patient values including CKM as a treatment option (7). Second, we must develop a CKM pathway that is evidence-based with best practice guidelines. Currently, the CKM option is rarely provided and mostly exists at specialized nephrology programs that predominantly include nephrologists with palliative care training, largely depriving older people of this person-centered choice in other centers. To implement this person-centered treatment option to older people widely, CKM care models must be incorporated into routine nephrology care. Until then, nephrology practices can offer the CKM pathway by: 1) appointing and training a local champion (primary palliative care model); 2) developing collaborative clinical efforts with colleagues in palliative care (specialist palliative care); or 3) fostering joint clinical care models with skilled clinicians from primary care to engage in SDM as accomplished in the “Patient Priorities Care” program (8). Third, we must address existing structural barriers and financial incentives that do not support SDM and instead discourage CKM as a goal-concordant option. Many clinicians are limited by short visit times, which can prevent a full exploration of patient goals, despite the existing billing codes for “goals-of-care” conversations. Payers financially incentivize the dialysis default without