Barriers to Conservative Management Conversations: Perceptions of Nephrologists and Fellows-in-Training.

Background: Not all treatments are appropriate for all individuals with kidney failure (KF). Studies suggest that conversations surrounding end-of-life decisions occur too late or not at all. Objectives: The aim of this research was to identify perceived barriers to such discussions among nephrologists and nephrology fellows to determine if barriers differ by experience level. Design: Phase I consisted of semistructured telephone interviews with nephrologists and fellows. Phase II included focus groups with nominal group technique in which providers ranked barriers to discussions about not initiating/withholding dialysis (NIWD) or discontinuing dialysis (DD). Setting/Subjects: U.S. community-based nephrologists and nephrology fellows. Results: Seven interviews were conducted with each group (n = 14) in phase I. Many barriers cited were similar among providers, however, differences were related to fellows' position as trainees citing the "reaction of their attending/supervising physician or other providers" as a barrier to NIWD and "lacking their attending physician's support" as a barrier to DD. Six focus groups were conducted, nephrologists (n = 22) and fellows (n = 18), in phase II. The highest ranked barrier to NIWD for nephrologists was "discordant opinions among patient and family"; fellows ranked "time to hold conversation" highest. Nephrologists' highest barrier to DD was the "finality of the decision (death)"; fellows ranked the "inertia of the clinical encounter" highest. Conclusions: Capturing the perspectives of nephrologists and fellows concerning the barriers to conservative management of patients with KF may inform the development of targeted education/training interventions by experience level focused on communication skills, conflict resolution, and negotiation.

Attitudes of Dialysis Unit Physicians with Regard to Withholding and Withdrawing Dialysis / 대한신장학회지

PURPOSE:In many countries, patients and dialysis unit physicians attempt to address issues regarding withholding and withdrawing dialysis through advance directives and clinical guidelines for dialysis utilization. However, there are only a few reports of withholding and withdrawing dialysis in Korea. This study was developed to investigate the attitudes of dialysis unit physicians regarding withholding and withdrawing dialysis in Korea. METHODS:A questionnaire survey was conducted among 45 dialysis unit physicians from January, 2006 to January, 2008. Physicians were asked about their decision making process to withhold and withdraw dialysis, and their opinions regarding the necessities of advance directives and guidelines for withholding and withdrawing dialysis. RESULTS:Analysis of surveys revealed that physicians agreed more about whether to withhold and withdraw dialysis in vegetative patients compared to patients with dementia ( p<0.001, p<0.001). There were more agreements about whether to withhold dialysis than whether to withdraw dialysis in patients with unimpaired cognition ( p<0.037). However, there were no differences in agreements between withholding and withdrawing dialysis in patients with severe neurological impairments. There appeared to be a general consensus regarding the need for guidelines addressing withholding and withdrawing dialysis (84.4%). However, opinions supporting the necessity for advance directives were not strongly favored (33.3%). CONCLUSION:Conflicting opinions are present among dialysis unit physicians regarding whether to withhold and withdraw dialysis according to a patient's neurological impairments. However, most dialysis unit physicians were of one accord regarding the need of guidelines for withholding and withdrawing dialysis.

Attitudes of Dialysis Unit Physicians with Regard to Withholding and Withdrawing Dialysis / 대한신장학회지

PURPOSE:In many countries, patients and dialysis unit physicians attempt to address issues regarding withholding and withdrawing dialysis through advance directives and clinical guidelines for dialysis utilization. However, there are only a few reports of withholding and withdrawing dialysis in Korea. This study was developed to investigate the attitudes of dialysis unit physicians regarding withholding and withdrawing dialysis in Korea. METHODS:A questionnaire survey was conducted among 45 dialysis unit physicians from January, 2006 to January, 2008. Physicians were asked about their decision making process to withhold and withdraw dialysis, and their opinions regarding the necessities of advance directives and guidelines for withholding and withdrawing dialysis. RESULTS:Analysis of surveys revealed that physicians agreed more about whether to withhold and withdraw dialysis in vegetative patients compared to patients with dementia ( p<0.001, p<0.001). There were more agreements about whether to withhold dialysis than whether to withdraw dialysis in patients with unimpaired cognition ( p<0.037). However, there were no differences in agreements between withholding and withdrawing dialysis in patients with severe neurological impairments. There appeared to be a general consensus regarding the need for guidelines addressing withholding and withdrawing dialysis (84.4%). However, opinions supporting the necessity for advance directives were not strongly favored (33.3%). CONCLUSION:Conflicting opinions are present among dialysis unit physicians regarding whether to withhold and withdraw dialysis according to a patient's neurological impairments. However, most dialysis unit physicians were of one accord regarding the need of guidelines for withholding and withdrawing dialysis.