Choosing wisely and beyond: shared decision making and chronic kidney disease

Abstract

In 2012, the Kaiser Permanente Area Medical Directors of Quality decided to sponsor analytic activities to improve shared decision making for patients with chronic kidney disease. The objective was to move shared decision making for renal replacement therapy or maximal conservative management upstream rather than waiting until the patient presented to the emergency room requiring acute dialysis. Nephrologists have multiple opportunities to discuss treatment options with patients throughout the course of their disease. However, despite these opportunities most patients beginning dialysis have not experienced shared decision making with their physicians. The shared-decision-making process may help patients understand the importance of being prepared to start dialysis and the benefits of maximal conservative management.By having these discussions upstream we may be able to improve survival (save lives), slow down renal disease progression (save kidneys), preserve central veins for future vascular access (save veins), and be better stewards of finite resources needed to care for patients with end-stage kidney disease (save resources).

Figure 1.

The top of the figure illustrates how the topic of life-sustaining treatment and the topic of palliative care can be integrated in discussions with the patient as the disease progresses. This approach is in contrast to management of end-stage kidney disease with dialysis until the very end of life, which leaves the patient unprepared for death and dying. The bottom of the figure relates stage of kidney disease and estimated glomerular filtration rate (eGFR). Patients enter stage 4 chronic kidney disease (CKD) when their eGFR decreases below 30 mL·min⁻¹·1.73 m⁻². Each additional decrease of approximately 5 mL·min⁻¹·1.73 m⁻² corresponds to the following substage. The arrows indicate 3 stages when shared decision making is critical.