Barriers to Conservative Management Conversations: Perceptions of Nephrologists and Fellows-in-Training

Abstract

Background:

Not all treatments are appropriate for all individuals with kidney failure (KF). Studies suggest that conversations surrounding end-of-life decisions occur too late or not at all.

Objectives:

The aim of this research was to identify perceived barriers to such discussions among nephrologists and nephrology fellows to determine if barriers differ by experience level.

Design:

Phase I consisted of semistructured telephone interviews with nephrologists and fellows. Phase II included focus groups with nominal group technique in which providers ranked barriers to discussions about not initiating/withholding dialysis (NIWD) or discontinuing dialysis (DD).

Setting/Subjects:

U.S. community-based nephrologists and nephrology fellows.

Results:

Seven interviews were conducted with each group (n = 14) in phase I. Many barriers cited were similar among providers, however, differences were related to fellows' position as trainees citing the “reaction of their attending/supervising physician or other providers” as a barrier to NIWD and “lacking their attending physician's support” as a barrier to DD. Six focus groups were conducted, nephrologists (n = 22) and fellows (n = 18), in phase II. The highest ranked barrier to NIWD for nephrologists was “discordant opinions among patient and family”; fellows ranked “time to hold conversation” highest. Nephrologists' highest barrier to DD was the “finality of the decision (death)”; fellows ranked the “inertia of the clinical encounter” highest.

Conclusions:

Capturing the perspectives of nephrologists and fellows concerning the barriers to conservative management of patients with KF may inform the development of targeted education/training interventions by experience level focused on communication skills, conflict resolution, and negotiation.