Shared Decision-Making on Kidney Function Replacement
Peritoneal dialysis (PD) is not a new development, but its significance is becoming increasingly recognized. Until recently, we may not have fully appreciated its value, but in light of the global threat posed by the current pandemic, its importance is starkly clear. PD is an accessible solution designed for home care and allows patients to avoid visits to healthcare facilities to some extent.
Who Are Our Patients?
We should first consider who the patients are that we regard as candidates for peritoneal dialysis. A significant portion of them are anxious and stressed about their situation, and they are disadvantaged in various ways, not just physically and medically. Therefore, we are dealing with chronically ill or polymorbid patients.
Patients' Interests and Needs vs. Cooperation Challenges
Patients need thorough and adequate education and should be informed about their prognosis if they wish to know. Most importantly, they need support and responsiveness. The prescription of dialysis should take into account their interests − both health-related and psychosocial.
Consequently, the outcome of therapy should be evaluated not only by laboratory and other objective results but also by the patient's interpretation of their current state and the success of their treatment. This should be the most important aspect of cooperation. The patient's experience should guide the next care objective. Since every patient has different preferences, needs, and values, it is crucial to make time for a targeted conversation during clinical examination. A close person may participate in this conversation if the patient wishes, especially if their communication abilities are impaired, for example, due to aphasia or cognitive deficit.
People with chronic kidney insufficiency also face more frequent socioeconomic problems and, on a global scale, have poorer knowledge regarding the human body, health, and illness. This makes it harder to establish quality contact, properly educate them, and reach a consensus on future solutions. The physician must be determined in these matters and direct the conversation towards a clear goal − an agreement on treatment and its form.
From the Patients' Perspective: What Are They Deciding?
When choosing a therapeutic modality, it is beneficial to consider the issue from the patient's perspective.
- First, patients decide whether they even want kidney function replacement. For those in generally poor health and at stage 5 chronic kidney disease (CKD), the benefit of dialysis may be minimal, and it may mainly represent discomfort, pain, and an intolerable disruption of their usual lifestyle (which is particularly significant at the end of life). Therefore, they need to know their prognosis and, above all, have insight into their quality of life − if it is expected to be the same with or without dialysis, opting for palliative care is entirely legitimate.
- Second, they choose the method of dialysis. Every patient who decides on kidney function replacement has the right to be informed about all its modalities, including peritoneal dialysis, which provides significant benefits in home care in the given situation. During education, it is advisable to demonstrate PD and introduce patients to the team of professionals involved in their care, and potentially arrange meetings with patients who already use PD and can share their experiences. It is important to act openly and emphasize shared decision-making between doctor and patient, but also to remain aware that the patient may be deciding under pressure, stress, or depression.
The ideal is to tailor a solution to each patient, not only medically − it is equally important to recognize how the patient needs to communicate about their illness, its treatment, and their future. Audiovisual and written materials can be used as educational aids. Even for patients with weaker cognitive abilities and less developed abstract thinking, they need to understand and know the options and risks associated with their illness and treatment to make informed decisions.
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Source: Blake P. G., Brown E. A. Person-centered peritoneal dialysis prescription and the role of shared decision-making. Perit Dial Int 2020 May; 40 (3): 302−309, doi: 10.1177/0896860819893803.
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