Comparing Nephrologists’ Self-Reported Decision-Making Skills and Treatment Attitudes With Their Patients’ Experiences of Making Kidney Therapy Decisions and Receiving Nephrology Care
Restricted accessResearch articleFirst published online June, 2025
Comparing Nephrologists’ Self-Reported Decision-Making Skills and Treatment Attitudes With Their Patients’ Experiences of Making Kidney Therapy Decisions and Receiving Nephrology Care
Dialysis is often initiated in the United States without exploring patients’ preferred decision-making style, and conservative kidney management (CKM) is infrequently presented. To improve kidney therapy (KT) decision-making, research on nephrologists’ comfort with various decision-making styles, attitudes towards CKM, and reports of patients’ lived experiences with KT decision-making is needed.
Methods
We surveyed 28 nephrologists and 58 of their patients aged ≥75 years. The nephrologist survey was designed to gauge their comfort levels with decision-making styles and attitudes towards CKM. The patient survey assessed experiences in making KT decisions.
Results
The average age of nephrologists was 43 years, and that of patients was 82 years. Nephrologists rated themselves as comfortable with various decision styles: paternalistic (60.7%), shared decision-making (92.8%), and patient-driven decision-making (67.8%). Nearly 57% of nephrologists felt challenged or were neutral in determining CKM’s suitability, and 39% reported difficulties in discussing CKM with patients or were neutral. Only 38 % of patients recalled discussing CKM with their nephrologists, and a minority reported discussing CKM-related topics such as life expectancy (24.7%), quality of life (QOL) (45.1%), and end-of-life care (17.5%).
Conclusions
Most nephrologists displayed comfort with various decision-making styles; however, many described difficulties in guiding patients toward CKM. In contrast, patients reported gaps in vital aspects of KT decision-making and CKM choices, such as discussions of life expectancy, QOL, and end-of-life care. Raising awareness of blind spots in decision-making skills and educating nephrologists in KT decision-making to include CKM and other person-centered aspects of care are needed.
ResnicowKCatleyDGogginKHawleySWilliamsGC. Shared decision making in health care: theoretical perspectives for why it works and for whom. Med Decis Making. 2022;42(6):755-764. doi:10.1177/0272989x211058068
2.
DrieverEMStiggelboutAMBrandPLP. Patients’ preferred and perceived decision-making roles, and observed patient involvement in videotaped encounters with medical specialists. Patient Educ Counsel. 2022;105(8):2702-2707. doi:10.1016/j.pec.2022.03.025
3.
ChiWCWolffJGreerRDyS. Multimorbidity and decision-making preferences among older adults. Ann Fam Med. 2017;15(6):546-551. doi:10.1370/afm.2106
4.
AroraNKMcHorneyCA. Patient preferences for medical decision making: who really wants to participate?Med Care. 2000;38(3):335-341. doi:10.1097/00005650-200003000-00010
5.
ThompsonSCPittsJSSchwankovskyL. Preferences for involvement in medical decision-making: situational and demographic influences. Patient Educ Counsel. 1993;22(3):133-140. doi:10.1016/0738-3991(93)90093-c
6.
EndeJKazisLAshAMoskowitzMA. Measuring patients’ desire for autonomy: decision making and information-seeking preferences among medical patients. J Gen Intern Med. 1989;4(1):23-30. doi:10.1007/bf02596485
7.
Wrede-SachJVoigtIDiederichs-EgidiHHummers-PradierEDierksMLJunius-WalkerU. Decision-making of older patients in context of the doctor-patient relationship: a typology ranging from “self-determined” to “doctor-trusting” patients. Int J Family Med. 2013;2013:478498. doi:10.1155/2013/478498
8.
ThompsonGASeguraJCruzDArnitaCWhiffenLH. Cultural differences in patients’ preferences for paternalism: comparing Mexican and American patients’ preferences for and experiences with physician paternalism and patient autonomy. Int J Environ Res Publ Health. 2022;19(17):10663. doi:10.3390/ijerph191710663
9.
YılmazNGSchoutenBCSchinkelSvan WeertJCM. Information and participation preferences and needs of non-Western ethnic minority cancer patients and survivors: a systematic review of the literature. Patient Educ Counsel. 2019;102(4):631-650. doi:10.1016/j.pec.2018.11.018
10.
LantzPMJanzNKFagerlinA, et al.Satisfaction with surgery outcomes and the decision process in a population-based sample of women with breast cancer. Health Serv Res. 2005;40(3):745-767. doi:10.1111/j.1475-6773.2005.00383.x
11.
MossAH. Revised dialysis clinical practice guideline promotes more informed decision-making. Clin J Am Soc Nephrol. 2010;5(12):2380-2383. doi:10.2215/cjn.07170810
12.
BrennanFStewartCBurgessH, et al.Time to improve informed consent for dialysis: an international perspective. Clin J Am Soc Nephrol. 2017;12(6):1001-1009. doi:10.2215/cjn.09740916
13.
DavisonSNPommerWBrownMA, et al.Conservative kidney management and kidney supportive care: core components of integrated care for people with kidney failure. Kidney Int. 2024;105(1):35-45. doi:10.1016/j.kint.2023.10.001
WongSPYHebertPLLaundryRJ, et al.Decisions about renal replacement therapy in patients with advanced kidney disease in the US department of veterans affairs, 2000-2011. Clin J Am Soc Nephrol. 2016;11(10):1825-1833. doi:10.2215/cjn.03760416
16.
KaziBSDubersteinPRKlugerBM, et al.Prevalence and correlates of preference-concordant care among hospitalized people receiving maintenance dialysis. Kidney. 2023;4(6):e751-e758. doi:10.34067/kid.0000000000000131
17.
SaeedFSardarMADavisonSNMuradHDubersteinPRQuillTE. Patients’ perspectives on dialysis decision-making and end-of-life care. Clin Nephrol. 2019;91(5):294-300. doi:10.5414/cn109608
18.
SaeedFLadwigSAEpsteinRMMonkRDDubersteinPR. Dialysis regret: prevalence and correlates. Clin J Am Soc Nephrol. 2020;15(7):957-963. doi:10.2215/cjn.13781119
19.
LadinKLinNHahnEZhangGKoch-WeserSWeinerDE. Engagement in decision-making and patient satisfaction: a qualitative study of older patients’ perceptions of dialysis initiation and modality decisions. Nephrol Dial Transplant. 2017;32(8):1394-1401. doi:10.1093/ndt/gfw307
20.
LadinKPandyaRKannamA, et al.Discussing conservative management with older patients with CKD: an interview study of nephrologists. Am J Kidney Dis. 2018;71(5):627-635. doi:10.1053/j.ajkd.2017.11.011
ParvezSAbdel-KaderKPankratzVSSongMKUnruhMProviderK. Provider knowledge, attitudes, and practices surrounding conservative management for patients with advanced CKD. Clin J Am Soc Nephrol. 2016;11(5):812-820. doi:10.2215/cjn.07180715
23.
SalatHJavierASiewED, et al.Nephrology provider prognostic perceptions and care delivered to older adults with advanced kidney disease. Clin J Am Soc Nephrol. 2017;12(11):1762-1770. doi:10.2215/cjn.03830417
24.
LuckettTSpencerLMortonRL, et al.Advance care planning in chronic kidney disease: a survey of current practice in Australia. Nephrology. 2017;22(2):139-149. doi:10.1111/nep.12743
25.
SellarsMClaytonJMMortonRL, et al.An interview study of patient and caregiver perspectives on advance care planning in ESRD. Am J Kidney Dis. 2018;71(2):216-224. doi:10.1053/j.ajkd.2017.07.021
26.
KrupatERosenkranzSLYeagerCMBarnardKPutnamSMInuiTS. The practice orientations of physicians and patients: the effect of doctor-patient congruence on satisfaction. Patient Educ Counsel. 2000;39(1):49-59. doi:10.1016/s0738-3991(99)00090-7
27.
SchellJOPatelUDSteinhauserKEAmmarellNTulskyJA. Discussions of the kidney disease trajectory by elderly patients and nephrologists: a qualitative study. Am J Kidney Dis. 2012;59(4):495-503. doi:10.1053/j.ajkd.2011.11.023
28.
GoffSLEneanyaNDFeinbergR, et al.Advance care planning: a qualitative study of dialysis patients and families. Clin J Am Soc Nephrol. 2015;10(3):390-400. doi:10.2215/cjn.07490714
29.
DavisonSN. End-of-life care preferences and needs: perceptions of patients with chronic kidney disease. Clin J Am Soc Nephrol. 2010;5(2):195-204. doi:10.2215/cjn.05960809
30.
WachtermanMWMarcantonioERDavisRB, et al.Relationship between the prognostic expectations of seriously ill patients undergoing hemodialysis and their nephrologists. JAMA Intern Med. 2013;173(13):1206-1214. doi:10.1001/jamainternmed.2013.6036
31.
O’HareAMKurella TamuraMLavalleeDC, et al.Assessment of self-reported prognostic expectations of people undergoing dialysis: United States renal data system study of treatment preferences (USTATE). JAMA Intern Med. 2019;179(10):1325-1333. doi:10.1001/jamainternmed.2019.2879
32.
MurtaghFEAddington-HallJMEdmondsPM, et al.Symptoms in advanced renal disease: a cross-sectional survey of symptom prevalence in stage 5 chronic kidney disease managed without dialysis. J Palliat Med. 2007;10(6):1266-1276. doi:10.1089/jpm.2007.0017
33.
JawedAMoeSMMoorthiRNTorkeAMEadonMT. Increasing nephrologist awareness of symptom burden in older hospitalized end-stage renal disease patients. Am J Nephrol. 2020;51(1):11-16. doi:10.1159/000504333
34.
FletcherBRDamerySAiyegbusiOL, et al.Symptom burden and health-related quality of life in chronic kidney disease: a global systematic review and meta-analysis. PLoS Med. 2022;19(4):e1003954. doi:10.1371/journal.pmed.1003954
35.
MortonRLSnellingPWebsterAC, et al.Factors influencing patient choice of dialysis versus conservative care to treat end-stage kidney disease. CMAJ (Can Med Assoc J). 2012;184(5):E277-E283. doi:10.1503/cmaj.111355
36.
VasherSTOppenheimIMSharma BasyalPLeeEMHayesMMTurnbullAE. Physician self-assessment of shared decision-making in simulated intensive care unit family meetings. JAMA Netw Open. 2020;3(5):e205188. doi:10.1001/jamanetworkopen.2020.5188
37.
CombsSACulpSMatlockDDKutnerJSHolleyJLMossAH. Update on end-of-life care training during nephrology fellowship: a cross-sectional national survey of fellows. Am J Kidney Dis. 2015;65(2):233-239. doi:10.1053/j.ajkd.2014.07.018
38.
QuillTEAbernethyAP. Generalist plus specialist palliative care — creating a more sustainable model. N Engl J Med. 2013;368(13):1173-1175. doi:10.1056/NEJMp1215620
39.
DavidDBarnesDEMcMahanRDShiYKatenMTSudoreRL. Patient activation: a key component of successful advance care planning. J Palliat Med. 2018;21(12):1778-1782. doi:10.1089/jpm.2018.0096
40.
SchererJSRauMEKriegerA, et al.A pilot randomized controlled trial of integrated palliative care and nephrology care. Kidney. 2022;3(10):1720-1729. doi:10.34067/kid.0000352022
41.
RamerSJKoncickiHM. To dialysis and beyond: the nephrologist’s responsibility for advance care planning. Kidney Med. 2020;2(2):102-104. doi:10.1016/j.xkme.2020.02.002
42.
Kurella TamuraMO’HareAMLinEHoldsworthLMMalcolmEMossAH. Palliative care disincentives in CKD: changing policy to improve CKD care. Am J Kidney Dis. 2018;71(6):866-873. doi:10.1053/j.ajkd.2017.12.017
43.
SaeedFSchellJO. Shared decision making for older adults: time to move beyond dialysis as a default. Ann Intern Med. 2023;176(1):129-130. doi:10.7326/M22-3431
