1. Qualitative analysis of medical records pertaining to the decision to start maintenance dialysis shows that physician practices and clinical situations, namely acute illnesses, are greater drivers of dialysis initiation compared to patient preferences.
2. Physicians are more likely to view dialysis as necessary with an emphasis on safety. Patients hesitant to start dialysis are often thought of as “resistant”. Patient values and goals of care were rarely documented in medical records.
Evidence Rating Level: 3 (Average)
Study Rundown: Currently, little evidence is available to guide the timing of initiation of dialysis for patients with advanced renal disease. Outside of emergency indications the current literature has not demonstrated clear benefit or harm of early initiation of dialysis. However, there has been an increasing trend towards starting dialysis earlier in the disease course that has not been explained by changes in clinical indications or symptoms of advanced renal disease. This study was a qualitative analysis of electronic medical records from a Department of Veterans Affairs (VA) cohort in order to explore the factors that influence the decision to start dialysis. The results of the study demonstrated the dominance of three themes that influenced dialysis initiation: patterns of physician practice, clinical momentum where dialysis was initiated at time of acute illness or in preparation for procedures for attempts at “medical optimization,” and the relationship between physician and patient. Physicians viewed dialysis as inevitable and necessary for safety while patients who did not choose dialysis were often described as “resistant” or had their competency questioned due to concerns of uremic encephalopathy. Patient values and goals of care were rarely documented in the medical record.
The described study provides unique insight into the factors at play in the decision to initiate dialysis. As a qualitative study it does not represent all patients and was not an exhaustive investigation into different factors. The medical record as the sole source of information also limits insight into the specific concerns of patients unless physicians chose to document them.
In-Depth [qualitative study]: The described study utilized electronic medical records from a random sample of 1691 patients from the Department of Veterans Affairs treated between Jan 1, 2000 and Dec 31, 2009. Medical records from the year prior to dialysis initiation were reviewed and relevant passages were included for inductive content analysis. Two independent investigators coded factors present in the passages, which were then collected into prevailing themes by three independent investigators.
The majority of patients were male (98.3%), began hemodialysis (95.2%), initiated dialysis as inpatients (74.7%), and had signs/symptoms of chronic kidney disease at time of initiation (95.3%). Mean eGFR was 10.4mL/min/1.73 m2 at time of initiation. The prevailing themes at the conclusion of analysis were: “physician practices”, “sources of momentum”, and “patient-physician dynamics”. The former two were most important in starting dialysis, while the patient goals were often not well discussed or documented.
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