Background
Methods
Study design
Procedure
Recruitment
Quantitative video-observations
Qualitative stimulated recall interviews
Analysis
Results
Sample characteristics
Video-recorded consultations (n = 29) | ||
Duration (in minutes) | Mean (SD) ** | Range |
28:96 (12:42) | 14:46–62:51 | |
Type of consultations | Number (%) | |
- New | 5 (17) | |
- Control (i.e. follow-up consultations)**** | 24 (83) | |
Characteristics of patients in video-recorded consultations (n = 29) | ||
Mean (SD) | Range | |
Age (in years)*** | 71.4 (10.5) | 49–89 |
Sex | Number (%) | |
- Male | 15 (52) | |
- Female | 14 (48) | |
Characteristics of professionals in video-recorded consultations (n = 15) | ||
Mean (SD) | Range | |
Average number of consultations per professional | 2.1 (1.3) | 1–5 |
Sex | Number (%) | |
- Male | 6 (40) | |
- Female | 9 (60) | |
Profession | ||
- Nephrologist # | 13 (87) | |
- Specialist nephrologist nurse | 2 (13) | |
Interviews with patients (interviews conducted; n = 14) | ||
Mean (SD | Range | |
Duration (in minutes) | 54:23 (18:24) | 25:55–103:36 |
Age (in years) | 72.9 (8.1) | 57–83 |
Sex | Number (%) | |
- Male | 8 (57) | |
- Female | 6 (43) | |
Significant others present during interview | 7 (50%) | |
Interviews with professionals (interviews conducted; n = 16##) | ||
Mean (SD) | Range | |
Duration (in minutes) | 37:28 (10:55) | 22:55–69:58 |
Number of consultations discussed (n = 21##) per professional | 1.5 (0.7) | 1–3 |
3.2. Quantitative video observations
0 | 1 | 2 | 3 | 4 | Mean (SD) | |
---|---|---|---|---|---|---|
1. For the health issue being discussed, the clinician draws attention to or confirms the fact that there are alternate treatment or management options or that a decision needs to be taken. If the patient rather than the clinician draws attention to the availability of options, the clinician responds by agreeing that the options need deliberation. | 1 | 1 | 13 | 13 | 1 | 2.4 (0.8) |
2. The clinician reassures the patient or reaffirms that they will support the patient in informing them or deliberating the options. If the patient states that they have sought or obtained information before the meeting, the clinician supports the deliberation process. | 7 | 13 | 6 | 3 | 0 | 1.2 (0.9) |
3. The clinician gives information or checks understanding about the options that are considered reasonable (this can include taking no action), to support the patient in comparing alternatives. If the patient requests clarification, the clinician supports the process. | 0 | 3 | 18 | 4 | 4 | 2.3 (0.8) |
4. The clinician makes an effort to elicit the patient’s preferences in response to the options that have been described. When the patient states their preference, the clinician is supportive. | 2 | 4 | 6 | 14 | 3 | 2.4 (1.1) |
5. The clinician makes an effort to integrate the patient’s elicited preferences as decisions are made. If the patient indicates how best to integrate their preferences as decisions are made, the clinician makes an effort to do so. | 2 | 10 | 7 | 10 | 0 | 1.9 (1.0) |
Total | 12 | 31 | 50 | 44 | 8 | 50.9 (14.4) |
Qualitative stimulated recall interviews
Themes | Quotes |
---|---|
What is important in SDM for patients? | |
HCP’s opinion | I: And why do you think he is better able to decide? P: He knows everything about it [about dialysis], he knows the consequences, he knows the impact on your life. So, I am … I really like it when I ask for his advice, like, ‘“What would you advise, what do you think is the best thing for me to choose?” I like it when he answers honestly. P: Yeah, he’s the expert, and he knows. See, I only have information from stories and books. And he knows what it actually does to your life. So, I like that. Yes. - Female, aged 64 |
Medical options | P: I don’t know if … well, as a patient, you can of course have certain desires, but if that isn’t medically justified or possible, then that’s it, everything stops. And then there comes the input from the doctor, who says “Okay, that’s all well and good, but it probably won’t work for you”, or “We can start with that, but the question is whether we can keep it like that”. So there are other sides to the story too. I can have all those desires … I: Yes, and not everything is possible. P: Not everything is possible. - Male, aged 76 |
Consider the environment | I: And do you ask for the doctors’ advice and take that in mind? SO: Yes, I take it home and then we have a discussion at the table together. - Female, aged 68 |
Type of provision of information | SO: And we’ve visited people, through the arrangements of the hospital. At home with a woman, who has been doing this [PD dialysis] for 2.5 years. […]. P: Yes, and we were received very nicely by these people. Absolutely great. SO: That was a positive thing, of course … P: They showed us everything, how it [PD dialysis] works in everyday life, no secrets. Fantastic! I: Okay, well that’s very nice. P: And after that [after the visit], you look at it differently, you look at it very differently. - Female, aged 74 |
Timeline of SDM before starting treatment | SO: Yes, but you also thought it was a step further, that now you had to visit that vascular surgeon, that it [dialysis] is getting closer and closer. P: Yes, and you asked the doctor, “How long could it take if it stays that way?” Then she said, “It could take another year [before dialysis starts]”. If nothing gets in the way. SO: Yes, yes. It can take a year, but it can also be within a year [that dialysis starts]. They just can’t answer that. And they are very honest about that, I mean, if he gets sick [the patient], then dialysis could start right away. So they can’t say that [predict when dialysis will start] and they are honest about it. - Male, aged 77 |
What can patients themselves do better in SDM? | |
Take control during the conversation | P: Maybe I would interrupt him in the 80+ story, huh. That I would say, “Man, you don’t have to explain all that to me, that’s irrelevant in my situation.” That is maybe what I should have done during the conversation. Because he talked about it quite extensively [about conservative therapy]. So maybe I should have said “Yeah, but that’s not the case at all, so tell me more about the difference between haemodialysis and abdominal dialysis instead.” Maybe I could have been clearer about that because it’s still unclear to me. - Female, aged 64 |
Ask (more) questions | P: Maybe, I would ask the doctor, “Okay, I’m too young [for conservative treatment]. But what is conservative treatment exactly, how does it work? What medication is required? What’s the prognosis? How many years can you live on it? At what stage? There’s so much I don’t know. Also, I don’t know what stage I’m at now, regarding my kidney function – I don’t know. I forgot to ask her that question because I don’t know. - Female, aged 57 |
Take notes | I: Because, how do you do this when you forget things and sit at home and think, “What about that?” SO: Yes, then we’ll ask these questions the next time. […] You don’t write anything down, and that’s actually a typical human error. I: That you think you’ll remember what has been said? SO: I have to write that down! Use a cheat sheet and take it everywhere with you when you go somewhere. Just like when going out for groceries. - Female, aged 68 |
What can HCPs do better in SDM according to patients? | |
Be consistent and reliable when providing information | P: The information is correct, only I imagined when I got into this that I could only choose between three options. Namely doing nothing, home dialysis, or some other form of the two dialyses, abdominal dialysis, or in the hospital, right? But now he mentioned a transplant. But at the clinic, they told me transplantation was out of the question because I’ve turned 70 and that’s the limit. They said I didn’t stand a chance of getting a transplant. And now he suddenly provides me this option! - Male, aged 74 |
Provide more information | I: Because, even if you were going to have dialysis, you would like to receive a timeline? P: Yeah, rght, a timeline. For example, how long can I go on receiving dialysis until they say, “Well sir, your kidneys are now so bad that you need a kidney transplant.” And I actually missed that point; you do read a lot about that of course. I: About transplantation? P: Yeah, kidney transplants. And later on I thought, why hasn’t that been mentioned? - Male, aged 76 |
Share responsibility in SDM | P: In itself, I am satisfied. Only, if they say I need to prepare for dialysis treatment, I’dsay, “What’s the best treatment for me?” Now I have to decide for myself what that is. Of itself, there’s nothing wrong with that, but they may say that won’t suit me. I: Would you like more help with that? That they then go and see what suits you best? P: Actually yes. In consultation with me, of course. I: Yes, exactly. That you are really a team. P: Yes. Now, as I see it, it’s like, “Well, you go ahead and choose.” - Male, aged 74 |
Ask more questions | P: Maybe she should ask me, “Yes, why?” Ask me more about my reasons. Ask me why I say I don’t want dialysis. Dig deeper, like, “Why do you say that? How many children do you have? You have children, but do you want to see your children grow up?” I: Yes, asking for the reason behind it. P: Yes, exactly. - Female, aged 57 |
Look at the patient more holistically during SDM | P: A tip for her is to look at the whole picture and ask yourself what else is wrong with this man. [Besides his kidney disease] Because of course, I only come here for the kidneys, but in principle, liver and heart and so on are all there too. - Male, aged 66 |
Themes | Quotes |
---|---|
What is important in SDM for HCPs? | |
SDM is a continuing process | N: But, you know, that really is the tricky part of this type of conversation. It’s not one conversation in which the decision is made. […]. Patients don’t have to choose at the end of this consultation. So, that is the actual context in which you assess or have to assess these conversations. […] You know, I am not having this conversation with the idea of ending with a decision having been made. An initial conversation with the patient is a bit of an inventory, testing, what have you heard, is it all clear, what are their thoughts. You then proceed from that point. - Male, Nephrologist |
Patients being aware of all options and risks | N: Yes, I think I am making an important decision here, in which I do try to take her along. But that’s difficult. If you, as a patient, have a completely different picture of what a treatment is and what the consequences are, then you first have to completely update that patient about that. You know, “What does that conservative therapy actually mean to you, it does mean that you die much earlier, do you actually realize that?” Otherwise, you will make the wrong decision. And the great thing about these conversations is that it doesn’t have to be decided right away. […] So here we have laid an important foundation on which to move forward. - Female, Nephrologist |
Explore and validate patient’s motivation for options | N2: The key thing in such conversations is figuring out why is this patient choosing this kidney replacement therapy, what are the reasons, and why not choose the other? And to see if the patient’s arguments are correct. And whether the patient has a divergent image that is not correct that I may have to adjust. N1: Right. And I also think that the question you asked earlier – “What would you see as the best option?” – well, if patients choose that option, then that’s great. But if they choose something else, then you ask why. Why is this patient now choosing this option? - Female and male, Specialist Nephrology Nurse and Nephrologist |
Take control in SDM | N: So I sometimes think the questions you ask the patient have to be in depth to understand whether the patient got it. But at a certain point, it has to stop – in the sense that you don’t inadvertently project your own insecurity onto the patient, which also makes them insecure. [...] You try to push off your uncertainty, letting the patient decide. I’m not that kind of doctor. I think that if I can and must decide something, I will. But that’s also because I’m the expert. Then a patient can also rest assured that I am taking the lead. […] When it comes to complicated medical-technical matters, I think we as doctors should be in the lead. - Male, Nephrologist |
What contextual factors influence SDM? | |
Knowing the patient | N: Yes, I spoke to him [the patient] at length afterwards, and also called him later on. So I think we are now getting to know this gentleman a little bit better and also understanding better what suits him and which stage he was in. Because he came here, a little unaware and uninformed, whereas he’s the kind of guy who wants to be in control, and I did not realize that at the time. So I think we are able to connect to him better now. - Female and male, Specialized Nurse in Nephrology and Nephrologist |
General characteristics of the patient | N: Yeah, I find people [before starting treatment] who don’t want to hear anything about dialysis at all, and we have them too. […] They really don’t want to hear about it, and only want to talk about it “when the time comes”. […] You don’t want anyone to instantly start a treatment they know nothing about, especially if you can already see it coming. - Female, Nephrologist |
Time available before consultation and start treatment | N: So, I like to take time for a conversation. But sometimes we have consultations, with an average of 10 minutes per patient, and then there’s that continuous pressure of a full waiting room. People always appreciate it, though, when you give them time, which I actually always do when necessary. - Male, Nephrologist |
Differences between patient and HCP | N: And with her, she didn’t want something completely different than what I had thought of, or what could be suitable for her. I: And if it did, what would that have changed? N: Well, if she was someone who had a very strong treatment desire, where I would think that it doesn’t seem sensible on medical grounds, those are difficult conversations. - Female, Nephrologist |
The organization of care in CKD | N: That makes it easier, having patients who know what they’re talking about. He also has been educated here about the different forms of dialysis. That’s the way we do it here: we have a certain way of educating, putting the doctor at the back of the process. And that has also helped and worked here. - Male, Nephrologist |
What role do HCPs see for themselves in SDM? | |
As team player | N: But I think that as a nephrologist, you can also do a lot in this [providing information about conservative treatment], but also as a renal failure team, as a dietitian, social worker, nurses … they all play important roles in this. - Female, Nephrologist |
As information provider and advisor | N: Well, especially in the beginning, before they actually start treatment, I already start giving information. And my experience is that people often also need it. For some, the clearance [eGFR] is not that bad at all, but then questions arise. And then I usually refer them to the website, to read more information about it first. Because when people enter care for advanced chronic kidney disease, the clock’s already ticking. - Female, Nephrologist |
Eliciting, checking and adjusting information | N: This is also something I often talk about with patients [the course of kidney failure], because in my experience, people just don’t really know what happens. And just like the patient, I also had a cat who died of kidney failure [the patient thought she would experience the same course of kidney failure as her cat], and I thought I had to adjust that image, because yes, she probably will not die like a cat. I was afraid she had all kinds of weird images in her head. […] I think she really had to know this, just how it goes. - Female, Nephrologist |
As coach being supportive | N: Yes, I think that I am coaching and acting as a sounding board for this gentleman, I think, in the sense that he himself indicates what wishes and limits are, and I can also indicate what our wishes are and state the limits of what is and is not possible. It’s also to find out how he actually sees life and what he thinks about it, what role he has in it and what form suits it best. So, I actually try to think along with him to find a solution. […] So it’s mainly about hearing from him how he sees things, and returning it to him. He’s the kind of guy who can decide for himself, but who does need me as a sounding board. - Female, Nephrologist |
As a practitioner taking responsibility | N: Yes, here I was being persuasive again because it appears that there is something that he hasn’t fully understood. And then I take on my role as a doctor and try to explain how it works. I: But what exactly is persuasion? N: Well, not so much persuasion, that’s not the right word, but that I explain the possibilities. So, I rise above the conservation, and explain, “No, but, you didn’t quite understand this”: I‘m taking on a bit of a leading role in the conversation again. […] But, that’s why I’m here, that’s my job, and that’s not negative. - Female, Nephrologist |
What can HCPs themselves do better in SDM? | |
Let the patient talk (provide teach-back) | N: Look, on the one hand, I always really love to wrap up a conversation with some sort of summary and conclusion, also to check if we both have the same idea of what we have agreed on. Well, I did here [referring to the fragment from the video-recorded consultation], and on the one hand, you can also say that it was persuasive and I should have let the patient summarize what we decided. - Female, Nephrologist |
Ask the patient more questions | N: Well, he didn’t talk much and that gives me the feeling I was maybe talking too much [after looking at a fragment from the video-recorded consultation] […] Should I ask “What do you think about that?” more often. So, in between, give more back to that patient? Like, “We’ve now discussed this: is this clear to you?” That could perhaps be better – recapitulating every now and then. - Female, Specialist Nephrology Nurse |
Be clearer to the patient and take control | N1: Still, I should maintain control and provide structure in the conversation. Right from the beginning of the conversation too, saying “This is going too far for now; let’s discuss the basics first and then you can talk again with the nurse.” We should mention that earlier. N2: Yes, maybe I should have said quite early in the conversation that we’d noticed they weren’t well-enough informed yet and we have to go back to providing information. - Female and male, Specialist Nephrology Nurse and Nephrologist |
Persuasion in information provision | N1: I think – not so much in this conversation [referring to the video-recorded conversation] but rather in the process before that – that we could be a bit firmer. We [N1 & N2] already feel that PD would be a great option for this patient, therefore it is very important how you organize the provision of information about PD for him. N2: […] If we determine that someone should be informed, then we have a form for the nurse conducting the provision of information, in which the nephrologist’s preference for kidney replacement therapy is indicated. In some cases, the PD education comes first and the PD education is more extensive than the HD education, being a bit persuasive. - Female, Nephrologist in training |
Taking time for SDM | N: This is something you generally do over a longer period [the SDM process]. Sometimes you don’t, because you don’t have a lot of time, caused by rapidly deteriorating kidney function. But if you have time, then you have the time to talk about that [about options for kidney replacement therapy], so I think you should take that time. On the other hand, you shouldn’t keep dawdling. […] So we will get through, we will continue, a decision will come, and it will be taken together in the foreseeable future, without us keeping running in circles. - Female, Nephrologist |