Supporting Shared Decision-Making in Life-Altering Kidney Therapy Decisions for Older Adults: A Review

Older adults represent the fastest-growing population initiating dialysis in the US. For older adults with advanced chronic kidney disease (CKD), initiating dialysis is often the default option presented, as they are often ineligible for kidney transplant. This approach may not align with many older patients' goals, who often prioritize quality of life over life extension. Further, many older patients report not being informed about all available kidney therapy options. This narrative review provides a guide for primary care clinicians to collaborate closely with older adults, their families, and nephrologists to promote shared kidney therapy decision-making in advanced CKD.

Several options exist for older adults with advanced CKD. These include kidney transplant, which aims to prolong life while preserving a good quality of life; dialysis, which focuses on prolonging life; and conservative kidney management, which forgoes dialysis and transplant, prioritizing quality of life over life prolongation. Shared decision-making is a collaborative process in which clinicians and patients jointly develop a care plan based on the best available evidence, the patient's goals and prognosis, and a careful weighing of the pros and cons of each kidney therapy option. This process supports patients to achieve informed and goal-concordant decisions regarding CKD management after careful deliberation. For patients with decisional uncertainty or a desire to maintain the status quo, a time-limited trial of dialysis or a deciding not to decide approach, respectively, can be implemented.

Shared decision-making is essential to help older adults with advanced CKD understand therapy options and make goal-concordant decisions. Primary care clinicians' collaboration with nephrologists to promote shared decision-making and deliver patient-centered, coordinated care is critically important.