To dialyse or delay: a qualitative study of older New Zealanders’ perceptions and experiences of decision-making, with stage 5 chronic kidney disease

• Published in: BMJ open 2017-03, Vol.7 (3), p.e014781-e014781
• Main Authors: Lovell, Sarah, Walker, Robert J, Schollum, John B W, Marshall, Mark R, McNoe, Bronwen M, Derrett, Sarah
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Aging; Attitude to Health; Clinical Decision-Making; Decision making; Female; Health care; Hospitals; Humans; Interviews; Kidney diseases; Kidney Failure, Chronic - psychology; Kidney Failure, Chronic - therapy; Length of Stay; Male; Multiculturalism & pluralism; Nephrology; New Zealand; Older people; Patients; Perceptions; Peritoneal dialysis; Qualitative research; Quality of Life; Reimbursement; Renal Dialysis - psychology; Renal Medicine; Renal replacement therapy; Self Efficacy
• ISSN: 2044-6055; 2044-6055
• DOI: 10.1136/bmjopen-2016-014781

BackgroundIssues related to renal replacement therapy in elderly people with end stage kidney disease (ESKD) are complex. There is inadequate empirical data related to: decision-making by older populations, treatment experiences, implications of dialysis treatment and treatment modality on quality of life, and how these link to expectations of ageing.Study populationParticipants for this study were selected from a larger quantitative study of dialysis and predialysis patients aged 65 years or older recruited from three nephrology services across New Zealand. All participants had reached chronic kidney disease (CKD) stage 5 and had undergone dialysis education but had not started dialysis or recently started dialysis within the past 6 months.MethodologySerial qualitative interviews were undertaken to explore the decision-making processes and subsequent treatment experiences of patients with ESKD.Analytical approach: A framework method guided the iterative process of analysis. Decision-making codes were generated within NVivo software and then compared with the body of the interviews.ResultsInterviews were undertaken with 17 participants. We observed that decision-making was often a fluid process, rather than occurring at a single point in time, and was heavily influenced by perceptions of oneself as becoming old, social circumstances, life events and health status.LimitationsThis study focuses on participants' experiences of decision-making about treatment and does not include perspectives of their nephrologists or other members of the nephrology team.ConclusionsOlder patients often delay dialysis as an act of self-efficacy. They often do not commit to a dialysis decision following predialysis education. Delaying decision-making and initiating dialysis were common. This was not seen by participants as a final decision about therapy. Predialysis care and education should be different for older patients, who will delay decision-making until the time of facing obvious uraemic symptoms, threatening blood tests or paternalistic guidance from their nephrologist.Trial registration numberAustralasian Clinical Trials Registry ACTRN 12611000024943; results.