Shared Decision Making Plays an Important Role in Dialysis

In the final stage of chronic kidney disease, there are multiple ways to replace kidney function. Which path to take? Every expert has a certain opinion on this question, formed through years of practice, based on professional literature and recommended procedures, but it is also important to allow the patient to participate in the decision-making about their future life.

Communication is Crucial, a Middle Ground is Ideal

In the patient-doctor relationship, it is, of course, the doctor who possesses expertise and is responsible for the chosen solution, even if it is reached in consensus with the patient. However, it is the patient who will live with the result of the decision. In the former paternalistic model of the relationship, the doctor decided and informed the patient of their decision. The patient had the right to refuse the chosen treatment but could not influence its selection.

The other extreme is the relationship between a "customer" and a "healthcare provider," which, conversely, degrades the doctor to a level that does not acknowledge their competence in making any decisions. Fortunately, this scenario does not apply to the Czech Republic.

The ideal method of communication lies somewhere in the middle - in the form of shared decision-making. For them to decide together, the doctor must inform the patient about their health condition and treatment options. The patient should express their wishes and, together with the doctor, select the solution that is most feasible for them. The patient then bears (at least morally) part of the responsibility for the shared decision and is presumed to cooperate better in implementing a solution they chose themselves.

Of course, this option also has its difficulties. For example, some patients do not want it - they are not interested in information and do not want to share responsibility or decide. They just want the result. Even such a patient should have the option of shared decision-making. They can of course refuse it, and then the doctor decides alone and informs the patient - to the extent the patient chooses.

Ways to Increase Comfort and Compliance

Another problem may arise with patients who form an opinion about their illness based on unspecialized sources and choose a solution themselves. If they are on the right track, shared decision-making can be simpler. But if they are mistaken in their "diagnosis," the doctor may come under pressure to share a decision with a poorly informed and incompetent patient. On the other hand, a patient who sees genuine interest and long-term high-quality communication from their doctor, and is openly informed about their health condition, feels more comfortable and has less need to "improve" the care.

Chronic kidney failure represents a significant burden for patients, with one of the main stressors being the constant need to travel to healthcare facilities for dialysis. Peritoneal dialysis could mean a great organizational relief for them and, therefore, improve treatment tolerance and adaptation to their new life situation. Patients should have a chance to influence decisions about their future therapy, especially if it significantly affects their lives.

A Method Suitable for Nearly Half of Dialysis Patients

Home dialysis also has its challenges and is primarily suitable for patients who trust themselves to manage the device in a home environment. It may be problematic for individuals with lower hygiene standards or poorer living conditions - it is simply not a solution for everyone. According to experts, it could be suitable for up to 40% of patients with chronic kidney disease needing dialysis. This percentage is realistic in some European regions, and many Czech patients would surely welcome the option of comfortable home dialysis.

(pez)

Sources:
1. Ondřichová L. The hardest thing for a nephrologist is to respect patient expectations. Medical Tribune, 7th October 2019.
2. Folta A. A nurse has a valuable role in the patient's decision-making about treatment. This also applies to peritoneal dialysis. Florence, 15th September 2019.