Best Case/Worst Case: A Multisite Randomized Trial of Scenario Planning for Patients With Late-Stage Kidney Disease

Best Case/Worst Case (BC/WC) is a communication tool to support nephrologists and older adults with advanced chronic kidney disease with decisions about dialysis. We compared the effectiveness of training nephrologists to use BC/WC versus usual care on receipt of palliative care, quality of life (QOL), quality of communication, dialysis initiation, and death.

From February 2021 to December 2023, we enrolled patients at 10 US sites who were ≥ 60 years, had an estimated glomerular filtration rate (eGFR) ≤ 24 mL/min/1.73m², with estimated survival ≤ 18 months, and were considering dialysis initiation in the outpatient setting. We randomized nephrologists to intervention or usual care.

In this cluster randomized trial, we followed patients for up to 2 years using chart review and patient and caregiver surveys. The primary outcome was receipt of palliative care within 12 months of patient enrollment.

We enrolled 68 nephrologists (36 intervention) and 268 patients (105 intervention). On intention-to-treat analysis, receipt of palliative care within 12 months did not significantly differ between groups (hazard ratio (HR) 0.94, 95% Confidence Interval (CI), 0.59-1.52; p = 0.812). Patients of intervention nephrologists were more likely to initiate dialysis (HR, 1.50, 95% CI, 1.00-2.25; p = 0.048) and report worse QOL throughout the study (FACIT-Pal effect estimate, -6.51; 95% CI, -12.20, -0.81; p = 0.025; FACT-G effect estimate, -4.78; 95% CI, -8.35, -1.22; p = 0.010). We found no significant differences in intensity of treatment at the end of life, quality of communication, or on-study death between groups.

Training nephrologists to use the BC/WC communication tool does not significantly affect receipt of palliative care or other measurable clinical outcomes.

NCT04466865 (URL: clinicaltrials.gov/study/NCT04466865), registered 07/07/2020.