Discussions during shared decision-making in older adults with advanced renal disease: a scoping review

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Abstract

Objectives

This review summarises the information available for clinicians counselling older patients with kidney failure about treatment options, focusing on prognosis, quality of life, the lived experiences of treatment and the information needs of older adults.

Design

We followed the Joanna Briggs Institute Methodology for Scoping Reviews. The final report conforms to the PRISMA-ScR guidelines.

Data sources

PubMed, PsycINFO, CINAHL, Embase, Scopus, Web of Science, TRIP and online repositories (for dissertations, guidelines and recommendations from national renal associations).

Eligibility criteria for inclusion

Articles in English studying older adults with advanced kidney disease (estimated glomerular filtration rate <30 mL/min/1.73 m ²); published between January 2000 and August 2018. Articles not addressing older patients separately or those comparing between dialysis modalities were excluded.

Data extraction and synthesis

Two independent reviewers screened articles for inclusion and grouped them by topic as per the objectives above. Quantitative data were presented as tables and charts; qualitative themes were identified and described.

Results

248 articles were included after screening 15 445 initial results. We summarised prognostic scores and compared dialysis and non-dialytic care. We highlighted potentially modifiable factors affecting quality of life. From reports of the lived experiences, we documented the effects of symptoms, of ageing, the feelings of disempowerment and the need for adaptation. Exploration of information needs suggested that patients want to participate in decision-making and need information, in simple terms, about survival and non-survival outcomes.

Conclusion

When discussing treatment options, validated prognostic scores are useful. Older patients with multiple comorbidities do not do well with dialysis. The modifiable factors contributing to the low quality of life in this cohort deserve attention. Older patients suffer a high symptom burden and functional deterioration; they have to cope with significant life changes and feelings of disempowerment. They desire greater involvement and more information about illness, symptoms and what to expect with treatment.

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Most cited references 110

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Functional status of elderly adults before and after initiation of dialysis.

Manjula Kurella Tamura, Kenneth E. Covinsky, Glenn Chertow … (2009)

It is unclear whether functional status before dialysis is maintained after the initiation of this therapy in elderly patients with end-stage renal disease (ESRD). Using a national registry of patients undergoing dialysis, which was linked to a national registry of nursing home residents, we identified all 3702 nursing home residents in the United States who were starting treatment with dialysis between June 1998 and October 2000 and for whom at least one measurement of functional status was available before the initiation of dialysis. Functional status was measured by assessing the degree of dependence in seven activities of daily living (on the Minimum Data Set-Activities of Daily Living [MDS-ADL] scale of 0 to 28 points, with higher scores indicating greater functional difficulty). The median MDS-ADL score increased from 12 during the 3 months before the initiation of dialysis to 16 during the 3 months after the initiation of dialysis. Three months after the initiation of dialysis, functional status had been maintained in 39% of nursing home residents, but by 12 months after the initiation of dialysis, 58% had died and predialysis functional status had been maintained in only 13%. In a random-effects model, the initiation of dialysis was associated with a sharp decline in functional status, indicated by an increase of 2.8 points in the MDS-ADL score (95% confidence interval [CI], 2.5 to 3.0); this decline was independent of age, sex, race, and functional-status trajectory before the initiation of dialysis. The decline in functional status associated with the initiation of dialysis remained substantial (1.7 points; 95% CI, 1.4 to 2.1), even after adjustment for the presence or absence of an accelerated functional decline during the 3-month period before the initiation of dialysis. Among nursing home residents with ESRD, the initiation of dialysis is associated with a substantial and sustained decline in functional status. 2009 Massachusetts Medical Society

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Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5.

Angela Sheerin, Mark Harris, Paul Donohoe … (2007)

The number of elderly patients with chronic kidney disease (CKD) stage 5 is steadily increasing. Evidence is needed to inform decision-making for or against dialysis, especially in those patients with multiple comorbid conditions for whom dialysis may not increase survival. We therefore compared survival of elderly patients with CKD stage 5, managed either with dialysis or conservatively (without dialysis), after the management decision had been made, and explored which of several key variables were independently associated with survival. A retrospective analysis of the survival of all over 75 years with CKD stage 5 attending dedicated multidisciplinary pre-dialysis care clinics (n=129) was performed. Demographic and comorbidity data were collected on all patients. Survival was defined as the time from estimated GFR<15 ml/min to either death or study endpoint. One- and two-year survival rates were 84% and 76% in the dialysis group (n=52) and 68% and 47% in the conservative group (n=77), respectively, with significantly different cumulative survival (log rank 13.6, P<0.001). However, this survival advantage was lost in those patients with high comorbidity scores, especially when the comorbidity included ischaemic heart disease. In CKD stage 5 patients over 75 years, who receive specialist nephrological care early, and who follow a planned management pathway, the survival advantage of dialysis is substantially reduced by comorbidity and ischaemic heart disease in particular. Comorbidity should be a major consideration when advising elderly patients for or against dialysis.

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Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease?

M Juszczak, Laura Carson, Andrew Davenport … (2009)

There is ongoing growth of elderly populations with ESRD in Western Europe and North America. In our center, we offer an alternative care pathway of 'maximum conservative management' (MCM) to patients who elect not to start dialysis, often because of a heavy burden of comorbid illness and advanced age. The objective of our study was to compare clinical outcomes for patients who had ESRD and chose either MCM or renal replacement therapy (RRT). This is an observational study of a single-center cohort in the United Kingdom that evaluating 202 elderly (> or =70 yr) patients who had ESRD and had chosen either MCM (n = 29) or RRT (n = 173). We report survival, hospitalization rates, and location of death for this cohort. Survival was measured from a standardized 'threshold' estimated GFR of 10.8 ml/min per 1.73 m(2). Median survival, including the first 90 d, was 37.8 mo (range 0 to 106 mo) for RRT patients and 13.9 mo (range 2 to 44) for MCM patients (P < 0.01). RRT patients had higher rates of hospitalization (0.069 [95% confidence interval (CI) 0.068 to 0.070]) versus 0.043 [95% CI 0.040 to 0.047] hospital days/patient-days survived) compared with MCM patients. MCM patients were significantly more likely to die at home or in a hospice (odds ratio 4.15; 95% CI 1.67 to 10.25). A survey of the literature describing elderly ESRD outcomes is also presented. Dialysis prolongs survival for elderly patients who have ESRD with significant comorbidity by approximately 2 yr; however, patients who choose MCM can survive a substantial length of time, achieving similar numbers of hospital-free days to patients who choose hemodialysis.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date Collection: 2019

Publication date (Electronic): 24 November 2019

Volume: 9

Issue: 11

Electronic Location Identifier: e031427

Affiliations

[1 ] departmentDepartment of Nephrology , Launceston General Hospital , Launceston, Tasmania, Australia

[2 ] departmentSchool of Medicine , University of Tasmania , Hobart, Tasmania, Australia

[3 ] departmentNephrology Service , Hammersmith Hospital , London, UK

[4 ] departmentSchool of Health Sciences , University of Tasmania , Hobart, Tasmania, Australia

[5 ] departmentFaculty of Health , University of Tasmania , Launceston, Tasmania, Australia

[6 ] departmentDepartment of Nephrology , Royal Hobart Hospital , Hobart, Tasmania, Australia

Author notes

[Correspondence to ] Dr Rajesh Raj; drrajeshraj@ 123456gmail.com

Author information

Rajesh Raj http://orcid.org/0000-0003-4781-3255

Srivathsan Thiruvengadam http://orcid.org/0000-0002-2678-6190

Kiran Deep Kaur Ahuja http://orcid.org/0000-0002-0323-4692

Mai Frandsen http://orcid.org/0000-0001-7027-1445

Article

Publisher ID: bmjopen-2019-031427

DOI: 10.1136/bmjopen-2019-031427

PMC ID: 6887047

PubMed ID: 31767590

SO-VID: 9a712443-4978-497b-9cbe-75315ab9d8e3

License:

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

History

Date received : 03 May 2019

Date revision received : 21 October 2019

Date accepted : 23 October 2019

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ScienceOpen disciplines: Medicine

Keywords: dialysis,adult nephrology,geriatric medicine,end stage renal failure,adult palliative care,epidemiology

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ScienceOpen disciplines: Medicine

Keywords: dialysis, adult nephrology, geriatric medicine, end stage renal failure, adult palliative care, epidemiology

Discussions during shared decision-making in older adults with advanced renal disease: a scoping review

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Abstract

Objectives

Design

Data sources

Eligibility criteria for inclusion

Data extraction and synthesis

Results

Conclusion

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Karger: Nephrology

Most cited references 110

Functional status of elderly adults before and after initiation of dialysis.

Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5.

Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease?

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