How do clinicians communicate about treatment options to older patients with advanced kidney disease – and what difference does it make?

Jan 16 / Professor Lucy Selman and Dr Chloe Shaw
Every day in the UK, 10 people over 65 develop kidney failure and must decide on what treatment to have. As most of the people in this group are too unwell for transplantation, their choice is typically between dialysis or conservative kidney management (CKM), which involves all aspects of good kidney disease management without dialysis. Often, the kidney care team delivers conservative care alongside specialist palliative care clinicians, who are experts in managing symptoms and supporting people through the end-stage of illness. 

While dialysis generally lengthens life, this is not guaranteed for older people, especially those with additional health problems. And dialysis often reduces a patient’s quality of life: for most, it entails several lengthy visits to the hospital every week to receive haemodialysis, and it can be challenging both physically and psychologically.
People with kidney disease rely on their specialist clinicians to help them decide which treatment to have, but the way clinicians discuss treatment options varies widely, and so does the information they provide to their patients. This is reflected in the wide variation in patient ratings of the quality of decision-making support across kidney centres. As a result, there’s huge variation in treatment rates across the UK. In fact, there’s evidence that at some kidney centres about 5% of older people don’t have  dialysis, while at others 95% do. This stunning disparity suggests that treatment decision-making is not always person-centred (i.e. based on patients’ needs and preferences).  

The OSCAR study (Optimising Staff-Patient Communication in Advanced Renal Disease) is the first UK study to systematically investigate how kidney doctors and nurses communicate with older people with advanced kidney disease when they’re deciding what treatment to have. Here we summarise findings from the first paper from the study, which examined how clinicians frame treatment decisions – and what difference this makes. 

Methodology and study design

Between 2021 and 2022 we video-recorded 110 kidney outpatient consultations across four UK kidney centres with differing rates of CKM. These recordings included 94 patients with a mean age of 77 (65-97) and mean eGFR 15 mL/min (range 4–23). From these, we identified and analysed 20 consultations where the clinician listed treatment options.

The recordings were systematically analysed using a method called Conversation Analysis. This enabled us to identify common features of the ways clinicians communicate these treatment options to patients and explore the relationship between the communication approach used by the clinician and the patient’s engagement in the conversation.

Patients, their companions, and clinicians were also invited to complete a post-consultation survey about shared decision-making (the SDM-Q-9). These survey scores were then tested for association with the conversational approach used by the clinician.

Major findings: two approaches to presenting treatment options

We found clinicians used two main approaches when presenting treatment options. The more common approach was where CKM was presented as a subordinate option to dialysis. In this approach, CKM was not treated as a clear treatment option. In the second, less common approach, CKM and dialysis were both presented as valid treatment options. Table 1 below from Selman et al. (2024), provides a summary of the key features of each approach.

Table 1: Recurrent elements of the two approaches to presenting CKM

CKM as a main option (less common) CKM as a subordinate option (more common
CKM is framed as a clear treatment option:
  • Introduced as part of the main decision-making sequence
  • Labelled as a clear treatment option and CKM
  • Details of what is involved
  • CKM is not framed as only relevant or preferable to a minority of patients
  • The potential benefit(s) of CKM/limitations of dialysis are described
CKM is not framed as a clear treatment option:
  • Appended to the main decision-making sequence
  • Not labelled as a clear treatment option/CKM but as an omission (not having dialysis)
  • Minimal/no details of what is involved
  • Not having dialysis maybe ruled out as ‘not for you’
  • CKM is framed as relevant or preferable only to a minority of patients CKM is not clearly presented as having benefit to the patient

What difference does it make?

Which approach was used had important implications for patient engagement with the option of CKM. When CKM was presented as a main option, clinicians tended to provide patients with more opportunity to engage with it in the conversation – they were more likely to invite the patient’s perspective, and patients were more likely to evaluate CKM as a relevant option.

When CKM was presented as a subordinate option, in contrast, the clinician tended to move the conversation on, without providing an opportunity for questions, or inviting the patient’s perspective. Following this approach, patients did not positively evaluate CKM as relevant to them.

We also found that when CKM was presented as a main option, patients gave significantly higher scores for shared decision-making, post-consultation. This difference was found despite their being no difference in the length of consultation for each approach (the mean consultation time for each approach was 23 minutes).

Theoretical and practical implications

We are using these findings in the Talk CKD Options communication training intervention, designed for kidney clinicians who support older patients making this treatment decision. Talk CKD Options is being piloted in the spring of 2025. For further information, see the study webpage or email chloe.shaw@bristol.ac.uk.

Study limitations and opportunities for future research

The analysis is based on a limited number of cases. However, the pattern we have identified is robust and was found across a variety of settings and clinicians. 

Conclusion

We found that clinicians tend to present CKM as a subordinate option when talking to older patients with advanced kidney disease. In doing so, clinicians can limit the patient’s engagement with that option in the conversation, and their involvement in decisions about their future care. Providing options is therefore not enough – how treatment options are presented is crucial.  

Link and citation for published article

Selman LE, Shaw CB, Sowden R, Murtagh FE, Tulsky JA, Parry R, Caskey FJ, Barnes RK. Communicating treatment options to older patients with advanced kidney disease: a conversation analysis study. BMC nephrology. 2024 Nov 21;25(1):417. https://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-024-03855-w/metrics

Funding/declaration statement

This report represents independent research sponsored by the University of Bristol, conducted as part of an NIHR Career Development Fellowship to LS (CDF-2018-11-ST2-009). The views expressed in this article are those of the authors and not necessarily those of the NIHR, or the Department of Health and Social Care.