Risk communication during treatment decision-making conversations with older people with advanced kidney disease

Most older people with advanced kidney disease are medically ineligible for transplant, hence the treatments available are dialysis or conservative kidney management (CKM). Previous research indicates that in the information patients receive from clinicians, dialysis is often prioritised over CKM. However, there is evidence that for older people and those with other health issues, dialysis is not always more beneficial. The aim was to investigate whether and how risks and benefits are discussed in relation to these options in consultations, to convey CKM as a valid option.

Outpatient consultations were recorded across four UK renal units purposively selected for variability of CKM rates amongst patients age 65+ with Chronic Kidney Disease. All data are British English. A total of 30 conversations were identified which concerned a decision between dialysis and CKM (22 led by doctors and 8 led by nurses). These included 20 conversations where options were listed to undecided patients, eight where a prior decision was revisited, and two where a recommendation was made against dialysis. Conversations were analysed using conversation analysis.

We found that CKM was only treated as a valid option by patients when the risks, burdens and limited benefits of dialysis were framed as significant in terms of quality and/or length of life. We found the following aspects of clinician communication enabled patients to respond in a way that treated CKM as a valid treatment option: 1) talking about the impact of dialysis to a person's quality of life, 2) conveying uncertainty regarding the potential benefit of dialysis to length of life, 3) conveying risk as being personally relevant to the patient's circumstances.

Findings demonstrate how clinicians can convey information to patients about the risks of dialysis in advanced kidney disease to enable patients to recognise and consider CKM as a valid option.