#2303 Evaluating symptom burden and decision making in older people with advanced chronic kidney disease (CKD): a cross-sectional service evaluation
Authors: Lokman Iqbal , Moore Louise R , Nixon Andrew C 
Published: May 2024

Abstract

Background and Aims
The benefits of dialysis compared with conservative management (CM) are less certain in older people with advanced chronic kidney disease (CKD) living with frailty and multimorbidity. Symptom burden and quality of life can worsen following dialysis initiation; studies have reported that patients can experience dialysis decisional regret. We conducted a cross-sectional service evaluation to understand symptom burden, experience of shared decision making and decisional regret for older people receiving haemodialysis (HD) and CM at our trust.

Method
People from our trust aged 65 and older receiving HD (for 3 to 12 months) or CM were recruited between April and May 2023. Patients were approached on HD units or via telephone. Baseline demographic and clinical characteristic data were obtained from electronic patient records. A Clinical Frailty Scale (CFS) assessment was performed for each patient using the CFS app. Patients with a CFS score ≥5 were categorized as frail. Activities of daily living (ADL) were assessed using the KATZ ADL index. Patients completed questionnaires evaluating symptom burden (IPOS-Renal), experience of shared decision making (SHARED questionnaire) and decisional regret (Decision Regret Scale). Information about advance care planning (ACP) was recorded. Mann-Whitney U, independent samples T-tests, Chi-squared, and Pearson's correlation coefficient were calculated using Statistical Package for Social Scientists (SPSS).

Results
Twenty-five HD and 25 CM patients were included with mean age of 74.7 (SD=5.9) and 83.2 (SD=5.2) years old, respectively. Eleven (44%) HD patients and 9 (36%) CM patients were female. The most common co-morbidities were hypertension (n=32, 64%), diabetes (n=16, 32%) and ischaemic heart disease (n=14, 28%). There was no significant difference in frailty (HD n=15 [60%], CM n=17 [74%], p=0.307) or KATZ ADL score between the two groups (p=0.124)
There was no significant difference between mean total IPOS-renal scores (HD 13 [SD=8.5], CM 15 [SD=8], p=0.395). CM patients were significantly more affected by dyspnoea (p=0.014) and drowsiness (p=0.036). HD patients experienced more wasted time for appointments (p=0.001), mostly related to transportation issues.
CM patients had more discussions about other treatment options aside from the one chosen (p=0.036), had their opinions sought more (p=0.038) and felt welcome to consider different options (p=0.018). HD patients felt more informed that there was a preferred medical treatment for their advanced CKD (p=0.006).
HD patients regretted their treatment option more than CM patients (p=0.028). A moderately-negative correlation was found between shared decision making and regret (r=-0.455, p&lt;0.001).
Finally, CM patients had more ACP decisions documented than HD patients (CM n=14 [58%], HD n=6 [26%], p=0.025).

Conclusion
Symptom burden was similar between CM and HD patients (see Fig. 1). HD patients felt less involved during decision making than CM patients and experienced more regret about their treatment choice. It is vital that all treatment options, including CM, are openly and impartially discussed with patients to truly ensure shared decision making and minimise the likelihood of decisional regret.