#2465 How do renal clinicians present treatment options to older patients with advanced kidney disease and what difference does it make?
Authors: Selman Lucy E , Shaw Chloe , Sowden Ryann , Murtagh Fliss , Caskey Fergus , Tulsky James , Parry Ruth , Barnes Rebecca 
Published: May 2024

Abstract

Background and Aims
For older people with kidney failure, especially those with comorbidities or poor performance status, the survival benefits of dialysis are uncertain and its quality of life impact greatest. Conservative kidney management (CKM) can be a beneficial alternative. However, there is significant variation in treatment rates among older patients with kidney failure; the CKMAPPS study [1] found rates of older people receiving dialysis ranged from 5-95% across UK renal units. How clinicians communicate about treatment options influences patients’ decision-making, but this has been under-researched. The OSCAR study (Optimising Staff-Patient Communication in Advanced Renal disease) aimed to describe how kidney failure treatment options are presented by renal clinicians to older people (age 65+) with advanced chronic kidney disease (eGFR ≤20 mls/min/1.73 m2 within the last 6 months) and the implications of this for patient engagement with the decision.

Method
Outpatient consultations between doctors/nurses and eligible patients were recorded at 4 UK renal units with varying rates of CKM. Recorded consultations were screened to identify cases where clinicians presented treatment options for advanced kidney disease. Consultations where clinicians presented both dialysis and CKM were transcribed and analysed in detail using Conversation Analysis, focused on how dialysis and CKM were framed. Post-consultation, patients completed the Shared Decision-Making Questionnaire (SDM-Q-9). Comparisons were made between groups according to how treatment options were presented, using a non-parametric Median Test.

Results
A total of 110 outpatient consultations were recorded (104 audiovisual, 6 audio). Recordings included 38 doctors and nurses and 94 patients; mean patient age 77 (65-97), 33 female/61 male, mean eGFR 15 (range 4-23). Sequences where clinicians presented both dialysis and CKM as treatment options were analysed (n = 21). Two approaches to presenting CKM were identified: 1) CKM as a main option (n = 6; see Fig. 1), 2) CKM as a subordinate option (n = 15; see Fig. 2). The mean consultation length was the same in both groups (23 mins). Recurrent features of the first approach included: framing CKM as having potential personal benefits to the patient; explicitly labelling it as a treatment option; not framing it as an option preferred by or relevant to only a minority of patients. In contrast, when CKM was presented as a subordinate option, recurrent features included: framing CKM as not having benefit to the patient; not explicitly labelling CKM as a treatment option; appending CKM to the main decision-making sequence; framing CKM as an option only chosen by a minority of patients. Presenting CKM as a main option alongside dialysis was a less common approach (n = 6 vs. n = 15), but associated with more interactional opportunities for patients to ask questions about CKM, assert their perspective, and assess CKM as a relevant option, as well as significantly higher patient ratings of shared decision-making (total SDM-Q-9 score, p = 0.041).

Conclusion
This is the first fine-grained analysis of the relationship between the conversational practices used by clinicians and their impact on patient engagement with treatment options and ratings of shared decision-making. Despite evidence that dialysis does not reliably extend older patients’ lives at acceptable costs to quality of life, we found that clinicians tend to present dialysis as the default treatment and CKM as subordinate, if at all. Our findings demonstrate that presenting treatment options is not enough; how clinicians present options has important implications for patient engagement in shared decision-making. To provide patients with the opportunity to evaluate CKM as a valid option requires clinicians to clearly detail the advantages and disadvantages of both treatments. Study findings will form the basis of a new communication training intervention for clinicians.