Barriers to Conservative Management Conversations: Perceptions of Nephrologists and Fellows-in-Training

Not all treatments are appropriate for all individuals with kidney failure (KF). Studies suggest that conversations surrounding end-of-life decisions occur too late or not at all. The aim of this research was to identify perceived barriers to such discussions among nephrologists and nephrology fellows to determine if barriers differ by experience level. Phase I consisted of semistructured telephone interviews with nephrologists and fellows. Phase II included focus groups with nominal group technique in which providers ranked barriers to discussions about not initiating/withholding dialysis (NIWD) or discontinuing dialysis (DD). U.S. community-based nephrologists and nephrology fellows. Seven interviews were conducted with each group (n = 14) in phase I. Many barriers cited were similar among providers, however, differences were related to fellows' position as trainees citing the "reaction of their attending/supervising physician or other providers" as a barrier to NIWD and "lacking their attending physician's support" as a barrier to DD. Six focus groups were conducted, nephrologists (n = 22) and fellows (n = 18), in phase II. The highest ranked barrier to NIWD for nephrologists was "discordant opinions among patient and family"; fellows ranked "time to hold conversation" highest. Nephrologists' highest barrier to DD was the "finality of the decision (death)"; fellows ranked the "inertia of the clinical encounter" highest. Capturing the perspectives of nephrologists and fellows concerning the barriers to conservative management of patients with KF may inform the development of targeted education/training interventions by experience level focused on communication skills, conflict resolution, and negotiation.