TY - JOUR
T1 - Treatment Decision Making for Older Kidney Patients during COVID-19
AU - Porteny, Thalia
AU - Gonzales, Kristina M.
AU - Aufort, Kate E.
AU - Levine, Sarah
AU - Wong, John B.
AU - Isakova, Tamara
AU - Rifkin, Dena E.
AU - Gordon, Elisa J.
AU - Rossi, Ana
AU - Di Perna, Gary
AU - Koch-Weser, Susan
AU - Weiner, Daniel E.
AU - Ladin, Keren
N1 - Funding Information:
K.E. Aufort reports research funding from Tufts University. G. Di Perna reports employment with Maine General Kidney Care and ownership interest in Crowdstrike and Palantir. E.J. Gordon reports the following honoraria and travel reimbursements for presentations and meetings: Advisory Committee on Blood and Tissue Safety and Availability (ACBTSA), the National Heart, Lung, and Blood Institute (NHLBI) Data and Safety Monitoring Board (DSMB), a National Institutes of Health ad hoc study section grant reviewer, and National Institute of Allergy and Infectious Disease (NIAID) DSMB. E.J. Gordon reports serving as a member of ACBTSA, an associate editor for American Journal of Transplantation, an associate editor for Narrative Inquiry in Bioethics, a member of National Academies of Science, Engineering and Medicine (NASEM) Committee, a member of NHLBI DSMB, and a member of NIAID DSMB and other interests or relationships as a member of the American Society of Transplantation Inclusion, Diversity, Equity and Access to Life (AST IDEAL) Task Force, a member of the AST Living Donor Community of Practice, and cochair of AST Psychosocial and Ethics Community of Practice (PSECOP). E. Gordon’s husband is a partner in Halock Security Labs, which is not related to health care. T. Isakova reports consultancy agreements with Akebia Therapeutics, Inc.; honoraria from Akebia Therapeutics, Inc.; consulting honoraria from Akebia Therapeutics, Inc., Kyowa Kirin Co., Ltd., and LifeSci Capital, LLC; and serving as an associate editor of American Journal of Kidney Diseases. S. Koch-Weser reports ownership interest in Performa Rowing LLC and research funding from the AB InBEV Foundation, which is fully funded by AB InBev. K. Ladin reports research funding from Dialysis Clinics, Inc., The Greenwall Foundation, National Institute of Nursing-National Institute of Nursing Research (NIN-NINR), the Patient-Centered Outcomes Research Institute, and Paul Teschan Research Fund 2021-08; serving in an advisory or leadership role for the Data Safety and Monitoring Board of the National Institute of Diabetes and Digestive and Kidney Diseases; and serving as chair of the ethics committee of Organ Procurement and Transplantation Network (OPTN) and United Network for Organ Sharing (UNOS). D.E. Rifkin reports serving as feature editor of American Journal of Kidney Diseases; serving on the American Board of Internal Medicine (ABIM) Nephrology Exam Committee; and serving as a coinvestigator of the US site for the Study of Heart and Kidney Protection With Empagliflozin (EMPA-KIDNEY) study (pending). A. Rossi reports employment with Piedmont Transplant Institute. D.E. Weiner reports research funding from Bayer (site principal investigator [PI]), CSL Behring (site PI), and Goldfinch Bio (site PI), with all compensation paid to Tufts Medical Center; consulting honoraria from Akebia Therapeutics (paid to Dialysis Clinics, Inc.) and Cara Therapeutics; serving as a member of the American Society of Nephrology (ASN) Quality and Policy Committees, an ASN representative to Kidney Care Partners (KCP), Medical Director of Clinical Research at Dialysis Clinics, Inc., Editor-in-Chief of Kidney Medicine, and Co–Editor-in-Chief of National Kidney Foundation’s Primer on Kidney Diseases, 8th Edition; serving on the scientific advisory board of the National Kidney Foundation; and other interests or relationships as a member of the data monitoring committee of the Feasibility of Hemodialysis with GARNET in Chronic Hemodialysis Patients with a Bloodstream Infection trial (Avania Contract Research Organization [CRO]), a member of the safety and clinical events committee for A Prospective, Multi-Center, Open-Label Assessment of Efficacy and Safety of Quanta SC1 for Home Hemodialysis trial (Avania CRO), and chair of the adjudications committee of the Veterans Affairs Lung Cancer Surgery Or Stereotactic Radiotherapy (VALOR) trial (George Institute, CRO; sponsored by Tricida). J.B. Wong reports serving as a panel member of the American Association for the Study of Liver Disease and Infectious Diseases Society of America, Recommendations for Testing, Managing, and Treating Hepatitis C; associate statistical editor of Annals of Internal Medicine; a member of the publications committee of the Massachusetts Medical Society; Interim Chief Scientific Officer of Tufts Medical Center; and a member of the US Preventive Services Task Force. All remaining authors have nothing to disclose.
Funding Information:
This work was supported by George M. O’Brien Kidney Research Center at Northwestern University grants NU-GoKIDNEY and P30DK114857; National Institutes of Health (NIH)/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) grants R01DK110087, P30DK114857, and U2CDK129917; and Patient-Centered Outcomes Research Institute (PCORI) grant CDR-2017C1-6297.
Publisher Copyright:
© 2022 by the American Society of Nephrology.
PY - 2022/7
Y1 - 2022/7
N2 - Background and objectives Coronavirus disease 2019 (COVID-19) disrupted medical care across health care settings for older patients with advanced CKD. Understanding how shared decision making for kidney treatment decisions was influenced by the uncertainty of an evolving pandemic can provide insights for supporting shared decision making through the current and future public health crises. Design, setting, participants, & measurementsWe performed thematic and narrative analyses of semistructured interviews with patients (CKD stages 4 and 5, age 701), care partners, and clinicians from Boston, Portland (Maine), San Diego, and Chicago from August to December 2020. Results We interviewed 76 participants (39 patients, 17 care partners, and 20 clinicians). Among patient participants, 13 (33%) patients identified as Black, and seven (18%) had initiated dialysis. Four themes with corresponding subthemes emerged related to treatment decision making and the COVID-19 pandemic: (1) adapting to changed educational and patient engagement practices (patient barriers to care and new opportunities for telemedicine); (2) reconceptualizing vulnerability (clinician awareness of illness severity increased and limited discussions of patient COVID-19 vulnerability); (3) embracing home-based dialysis but not conservative management (openness to home-based modalities and limited discussion of conservative management and advanced care planning); and (4) satisfaction and safety with treatment decisions despite conditions of uncertainty. Conclusions Although clinicians perceived greater vulnerability among older patients CKD and more readily encouraged home-based modalities during the COVID-19 pandemic, their discussions of vulnerability, advance care planning, and conservative management remained limited, suggesting areas for improvement. Clinicians reported burnout caused by the pandemic, increased time demands, and workforce limitations, whereas patients remained satisfied with their treatment choices despite uncertainty.
AB - Background and objectives Coronavirus disease 2019 (COVID-19) disrupted medical care across health care settings for older patients with advanced CKD. Understanding how shared decision making for kidney treatment decisions was influenced by the uncertainty of an evolving pandemic can provide insights for supporting shared decision making through the current and future public health crises. Design, setting, participants, & measurementsWe performed thematic and narrative analyses of semistructured interviews with patients (CKD stages 4 and 5, age 701), care partners, and clinicians from Boston, Portland (Maine), San Diego, and Chicago from August to December 2020. Results We interviewed 76 participants (39 patients, 17 care partners, and 20 clinicians). Among patient participants, 13 (33%) patients identified as Black, and seven (18%) had initiated dialysis. Four themes with corresponding subthemes emerged related to treatment decision making and the COVID-19 pandemic: (1) adapting to changed educational and patient engagement practices (patient barriers to care and new opportunities for telemedicine); (2) reconceptualizing vulnerability (clinician awareness of illness severity increased and limited discussions of patient COVID-19 vulnerability); (3) embracing home-based dialysis but not conservative management (openness to home-based modalities and limited discussion of conservative management and advanced care planning); and (4) satisfaction and safety with treatment decisions despite conditions of uncertainty. Conclusions Although clinicians perceived greater vulnerability among older patients CKD and more readily encouraged home-based modalities during the COVID-19 pandemic, their discussions of vulnerability, advance care planning, and conservative management remained limited, suggesting areas for improvement. Clinicians reported burnout caused by the pandemic, increased time demands, and workforce limitations, whereas patients remained satisfied with their treatment choices despite uncertainty.
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U2 - 10.2215/CJN.13241021
DO - 10.2215/CJN.13241021
M3 - Article
C2 - 35672037
AN - SCOPUS:85134196210
SN - 1555-9041
VL - 17
SP - 957
EP - 965
JO - Clinical Journal of the American Society of Nephrology
JF - Clinical Journal of the American Society of Nephrology
IS - 7
ER -
