Alvin Moss @AMOSS7 

Alvin Moss is a Professor of Medicine at the West Virginia University School of Medicine in the Sections of Nephrology and Geriatrics and Palliative Medicine. He chairs the Coalition for the Supportive Care of Kidney Patients. His research interests include dialysis ethics and improving care at the end of life.

Copyright: Kaspars Grinvalds / Shutterstock

Competitors for the Ethics Region:

Policy-Driven Outcomes for Dialysis vs Patient-Driven Choice for Dialysis

End-of-Life Care for Patients on Dialysis vs Dialysis for Patients at End-of-Life

Nephrologists want to deliver high-quality care and enable their patients to be “winners” of evidence-based treatment. Supporting “Patient-Driven Choice for Dialysis“ provides nephrologists with an opportunity to step up their game and bring home the trophy for providing care that matters most to their patients!

In publishing Crossing the Quality Chasm: A New Health Care System for the 21^st Century in 2001, the Institute of Medicine (IOM) acknowledged that the US health care delivery system does not provide consistent, high-quality medical care. The IOM issued an urgent call for fundamental change based on six aims to improve key dimensions. One of those aims relevant to dialysis patient choice is patient-centered care. The IOM defined it as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.” The IOM recommended shared decision-making, the process in which patients are informed about their treatment options and reach agreement with their physicians about health care decisions that affect them. Writing in the New England Journal of Medicine, Barry noted that shared decision-making is the pinnacle of patient-centered care!

In the 21^st century, medicine entered into a new era. Care should no longer be disease-oriented but should focus on what matters most to the patient, no longer dialysis-driven but patient-driven, and no longer “one-size-fits-all” in which patients with advanced chronic kidney disease (CKD) are automatically assumed to want dialysis and prepared to start it. Implementing shared decision-making is the way that nephrologists will improve their care of their patients with CKD and give them control over their health care.

“Patient-Driven Choice for Dialysis“ is the most important thing in nephrology now because in nephrology’s current disease-oriented approach, patients are losing out. They do not have the information they need to make informed decisions. Shared decision-making is poorly integrated into dialysis patient care. It is through shared decision-making that patient-driven choice for dialysis will be achieved!

In the process of shared decision-making, nephrologists are to elicit their patients’ values and preferences. Sadly, recent research shows that most nephrologists do NOT know their patients’ values, preferences and priorities; patients with kidney disease are heterogeneous in their values. Most patients value independence over living as long as possible, and they are willing to trade length of survival for comfort and avoidance of suffering.

The reason why nephrologists should take note of these findings is that three of their major nephrology professional societies – American Society of Nephrology, National Kidney Foundation (NKF), and Renal Physicians Association -are all urging them to change their current practice and engage their patients in shared decision-making to provide them with high quality individualized, patient-centered care. The National Kidney Foundation in conjunction with Tufts University has launched a three-year project, “Promoting Autonomy and Improving Shared Decision Making for Older Adults with Advanced Kidney Disease,” to help older patients with advanced stages of kidney disease and their family make decisions that best reflect their goals and preferences for care. NKF Chief Medical Officer, Joseph Vassalotti, MD, said that many older chronic kidney disease patients “may have difficulty deciding between dialysis and medical management, and they are often poorly informed about the relative harms and benefits of these two strategies, including how either one could affect the duration and quality of their life.”

Patients with stage 5 CKD have multiple potential options for treatment for their end-stage kidney disease: kidney transplantation, home peritoneal dialysis, home hemodialysis, in-center hemodialysis, and medical management without dialysis. It is time for patients to be well-informed by their nephrologists through shared decision-making about their options based on their overall condition and for patients to make the decision. In so doing, nephrologists will be furthering the Advancing American Kidney Health Initiative which seeks to encourage kidney transplantation and home dialysis.

In 2020, nephrologists can implement “Patient-Driven Choice for Dialysis,” secure the NephMadness win, and cut down the net for their patients!

– Guest Post written by Alvin Moss @AMOSS7 

As with all content on the AJKD Blog, the opinions expressed are those of the author of each post, and are not necessarily shared or endorsed by the AJKD Blog, AJKD, the National Kidney Foundation, Elsevier, or any other entity unless explicitly stated.

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