Decision-making about dialysis: Beyond just dialysis or death.

Nearly half of the persons receiving dialysis in the United States are aged 65 years or older. Kidney failure occurs most frequently in older adults, and typically triggers a discussion regarding dialysis treatment. In this Special Article, we describe the journey of Mr. Howard Russell, an older adult who experienced kidney failure and underwent dialysis. Using the experience of Mr. Russell, we illustrate the complexity of dialysis decision-making, including how disease trajectory and health policy can potentially impede older adults from achieving "what matters." Our intent is to provide guidance regarding these barriers and support to clinicians who are sharing similar journeys with older adults making decisions about dialysis. Based on Mr. Russell's journey, we suggest that when discussing dialysis with an older adult, four points be considered: (1) recognize if dialysis is needed long-term; (2) understand what matters for the older adult; (3) sync the treatment plan when what matters changes; and (4) set up with resources for kidney failure, which is limited but evolving.

A novel longitudinal geriatric medical student experience: using teaching objective structured clinical examinations.

It has previously been shown that medical students perform poorly when assessing older adults with recurrent falls. To address this and teach students about other geriatric syndromes, a standardized patient, played by one of nine actresses, aging during the course of an afternoon, was developed. The patient is first aged 75 with falls, then 80 with memory problems, then 82 with an acute confusional state. The third-year students interact with the patient on a one-to-one basis. After seeing and examining her, the students write up the case and then meet with the supervising physician after each section to discuss the case. This intervention was well accepted, scoring 5.95 on a 7-point Likert-type scale. At the end of the clinical year, the students participated in an eight-case clinical skills examination that included a 79-year-old man with falls. Using the actor's checklists, the performances of the 42 medical students who had participated in the standardized patient experience were compared with those of the 128 who had not. Over the eight cases, there was no difference in the three domains of communication, information gathering, and physical examination, but in the geriatric case, the students who had participated in the experience performed significantly better in all three domains. The intervention students were also three times as likely to examine the subject's gait (60% vs 20%). A 3-hour interactive session substantially improved specific geriatric competencies. One can only wonder what more dedicated time could accomplish.