Predialysis education: some cliffhangers

Transplantation Renal Replacement Therapy Hemodialysis Peritoneal Dialysis Options for End-Stage Renal Disease Patients

Integrated care 2010 Follow up Before dialysis Hemodialysis In centre dialysis Satellite Dialysis home hemo Nocturnal dialysis Daily dialysis Creatinine Clearance (ml/min) Start of dialysis Peritoneal dialysis Transplantation Cadaveric living donor “Old for old” PD APD CAPD Assisted PD

The Kidney Early Evaluation Program Tamura et al, KI, 2013

What modality of dialysis should I choose? Dialysis modality selection: Clinical advice from the European Renal Best Practice (ERBP) Advisory Board

What modality of dialysis should I choose? Dialysis modality selection: Clinical advice from the European Renal Best Practice (ERBP) Advisory Board

What modality of dialysis should I choose? Dialysis modality selection: Clinical advice from the European Renal Best Practice (ERBP) Advisory Board

P ersonalised D ialysis –“informed patient choice” –Pre dialysis programs

Barriers at the provider level?

Odds of receiving PD as first line treatment Komenda et al, submitted

Hingwala et al, NDT, 2013 Patient survival

Hingwala et al, NDT, 2013 Technique survival

Patient perspectives on informed decision- making surrounding dialysis initiation Song et al, NDT, 2013

Sources of patient information Ceapir survey, Van Biesen et al, submitted

Sources of patient information Ceapir survey, Van Biesen et al, submitted Patients that were involved with decision making were much more likely to be satisfied with their treatment (OR 3.13 (95% CI )

Morton et al, BMJ, 2009

Patient Information: Predialysis 1.Patients do not recall having been informed at all 2.Patients are informed “too late” i.e. in a state when they are uraemic, desperate, depressed by their diagnosis…. Language too difficult Irrelevant information Too much information 3.Their is a “communication problem” between medical staff and patients on which topics/factors to value Empathic listening Motivational interviewing 4.Patients tend to make heuristic, not objective decisions Danger of exposing them to other patients

Shared decison making

1.Making the options clear 2.Help the patient with making an informed choice 1.Value Clarification 2.Elicit patient preferences 3.Avoid bias by your own beliefs and values 4.Suggest solutions that fit these values and preferences 5.Facilitate decision making

Shared decison making 1.Making the options clear 2.Help the patient with making an informed choice 1.Elicit patient preferences 2.Suggest solutions that fit these preferences 3.Facilitate decision making Inform

(but the information does not exist)

(but the information does not exist) Is APD better than CAPD?

Relative risk CAPD vs APD Mehrotra et al, KI 2009

Survival CAPD vs APD Michels et al, cJASN, 2009

Survival CAPD vs APD Badve et al, KI 2008

Survival fast transporters APD vs CAPD Johnson et al, NDT, 2010 APD survival superior in fast transporters, but CAPD better in slow transporters

Incident patient vs 90-day Analyses Quinn JASN 22:

Probabilityambiguity complexity CONTEXT

Shared decison making 1.Making the options clear 2.Help the patient with making an informed choice 1.Value Clarification 2.Elicit patient preferences 3.Suggest solutions that fit these preferences 4.Facilitate decision making Inform Deliberate

Morton et al, BMJ, 2009

Anchoring (+Halo effect) Attribution Availability

Nephrology fellow Nephrologist Head nurse operating theatre anesthesist nutrition Supervisor PD Head nurse Nephrology Surgeon Team management!!!

Approaches to Value Clarification/Preference Elicitation process: interactive eg using sliding scales, ordering cards etc 1.assumptions: a.working "interactive" provides the patient with insight in his/her preference b.the patient has to make his preference clear to the other person 2.can be indirect (ask questions outside the question at end to obtain general preference) or direct 3. always be careful to avoid decision regret and increased anxiety in patients 4. always be careful to avoid "unbalanced" "coloured" phrasings non interactive eg video, dvd, booklets, patient stories, case scenarios: 1.this can be dangerous as they provide information in a linear fashion, and do not allow the "PE" step, which has to be made by the patient himself; 2.underlying assumption: patient will take the VC step while going through the information and will do the PE step later

Shared decison making 1.Making the options clear 2.Help the patient with making an informed choice 1.Elicit patient preferences 2.Suggest solutions that fit these preferences 3.Facilitate decision making Inform Deliberate Decide

Yodda: inform Available on:

Yodda: deliberate Haemodialysis Peritoneal Dialysis

Yodda: deliberate

Yodda: helping in decision

“Shared Decision Making”