Shared Decision-Making in CKD: Lessons From Advance Care Planning in Taiwan

Advance care planning (ACP) is increasingly viewed as part of the broader continuum of shared decision-making, especially in chronic kidney disease (CKD) in which patients face complex treatment choices. Taiwan, with the world's highest kidney failure prevalence and a national ACP policy, provides a unique context to examine how patients and caregivers engage with ACP when it is separated from nephrology care. This study explored factors influencing ACP engagement among patients with moderate-to-severe CKD and their caregivers.

An exploratory qualitative study using semi-structured interviews and inductive thematic analysis.

Sixteen individuals were recruited from a rural tertiary center in Taiwan (June 2020 to August 2020), including 9 patients with CKD stage 3-5 and seven unrelated caregivers. Interviews were conducted in Mandarin, Taiwanese, or Fuzhonese.

Patients' and caregivers' experiences with nephrology care and ACP services within the Taiwanese health care system.

Perceived facilitators and barriers to ACP engagement.

Transcripts were analyzed inductively using Braun and Clarke's framework. Two researchers coded independently with investigator triangulation; thematic saturation was reached after 16 interviews.

Six themes influenced ACP engagement: (1) trust in the nephrology care team; (2) differences in communication preferences between patients versus caregivers; (3) preference for in-person consultations; (4) greater ACP engagement among transplant patients; (5) sensitivity to service fees; and (6) cultural hesitation in engaging in ACP services.

Single-site recruitment, absence of member checking, and occasional use of semi-public spaces may have affected disclosure. Most participants had kidney-focused trajectories, limiting generalizability to older or frailer populations.

ACP should be integrated into the broader shared decision-making continuum of CKD care. Leveraging predictable clinical milestones, embedding ACP into nephrology workflows, and ensuring financial coverage may strengthen patient-centered decision-making. Taiwan's experience illustrates how system design, clinician roles, and culture shape shared decision-making internationally.