Predialysis education: some cliffhangers. Transplantation Renal Replacement Therapy Hemodialysis...

Predialysis education: some cliffhangers

Transplantation

RenalReplacement

Therapy

Hemodialysis Peritoneal Dialysis

Options for End-Stage Renal Disease Patients

Integrated care 2010Follow up

Before dialysis

Hemodialysis

•In centre dialysis

•Satellite Dialysis

• home hemo

•Nocturnal dialysis

•Daily dialysis

Cre

atin

ine

Cle

aran

ce

(ml/

min

)

20

15

10

5

0Start of dialysis

Peritoneal dialysisTransplantation• 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

www.european-renal-best-practice.org

What modality of dialysis should I choose?Dialysis modality selection:

Clinical advice from the European Renal Best Practice (ERBP) Advisory Board

www.european-renal-best-practice.org

2010

What modality of dialysis should I choose?Dialysis modality selection:

Clinical advice from the European Renal Best Practice (ERBP) Advisory Board

www.european-renal-best-practice.org

2010

Personalised Dialysis

– “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, 2013Patient survival

Hingwala et al, NDT, 2013Technique 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 2.72-3.60)

Morton et al, BMJ, 2009

Patient Information: Predialysis

1. Patients do not recall having been informed at all2. 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

Shared decison making

1. Making the options clear2. Help the patient with making an informed choice

1. Value Clarification2. Elicit patient preferences3. Avoid bias by your own beliefs and values4. Suggest solutions that fit these values and preferences5. Facilitate decision making

Shared decison making

1. Making the options clear2. Help the patient with making an informed choice

1. Elicit patient preferences2. Suggest solutions that fit these preferences3. Facilitate decision makingIn

form

(but the information does not exist)

www.european-real-best-practice.org

(but the information does not exist)

www.european-real-best-practice.org

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 22:1534 2011

Probability ambiguity

complexity

CONTEXT

Shared decison making

1. Making the options clear2. Help the patient with making an informed choice

1. Value Clarification2. Elicit patient preferences3. Suggest solutions that fit these preferences4. Facilitate decision making

Info

rmDeliberate

Morton et al, BMJ, 2009

Morton et al, BMJ, 2009

Anchoring (+Halo effect)AttributionAvailability

Nephrology fellow

NephrologistHead nurse operating theatre

anesthesist

nutrition

Supervisor PD

Head nurseNephrology

Surgeon

Team management!!!

Approaches to Value Clarification/Preference Elicitation process:

•interactiveeg using sliding scales, ordering cards etc

1.assumptions: a.working "interactive" provides the patient with insight in his/her preferenceb.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 direct3. always be careful to avoid decision regret and increased anxiety in patients4. always be careful to avoid "unbalanced" "coloured" phrasings

•non interactive eg video, dvd, booklets, patient stories, case scenarios: •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; •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 clear2. Help the patient with making an informed choice

1. Elicit patient preferences2. Suggest solutions that fit these preferences3. Facilitate decision makingIn

form Deliberate

Decide

Yodda: inform

Available on: www.european-renal-best-practice.org

Yodda: deliberateHaemodialysis Peritoneal Dialysis

Yodda: deliberate

Yodda: helping in decision

Yodda: helping in decision

“Shared Decision Making”