Strategies to address clinician hesitancy toward conservative care

Nephrology providers often face difficult situations in which dialysis many not provide meaningful benefit. Yet, data suggest most patients are preparing for, discussing or starting dialysis [1]. This discrepancy is striking given the emergence of conservative care (CC)—a treatment pathway for patients who may not benefit from dialysis and whose goals support a focus on quality of life. For older patients with advanced comorbidities, survival on CC is often comparable to dialysis but with more time spent out of the hospital, improved symptom management and timely end of life care [2, 3]. For CC to become part of routine nephrology care, providers must embrace CC as an efficacious treatment path and feel empowered to deliver this care. This practice change requires traditional nephrology practice to shift from a biometric focus toward one that is patient-centered. Nephrology providers report multiple barriers to incorporating CC into practice [4]. We believe these barriers are surmountable and present three principles to address clinician hesitancy toward CC. Nephrology providers worry that talking about CC will take away hope, yet data suggest patients want information about their prognosis and what to expect in the future [5]. In fact, patients need guidance to make informed decisions about treatment options. This often includes an honest discussion of prognostic worries. For patients with limited prognosis, survival time on dialysis often comes at the cost of functional impairment and increased hospitalizations. This experience is striking since many patients and caregivers prioritize quality of life over survival alone [6]. Therefore, providing meaningful prognostic information helps patients make treatment decisions that align with their values and priorities. We recommend a communication framework called REMAP for discussing goals of care to inform kidney treatment decisions [7]. This five-step framework starts with providing a Reframe or big picture prognosis that supports why a goals of care conversation is necessary. This big-picture prognosis should be relayed in language that is meaningful to patients including functional outcomes and general survival timelines. After providing prognostic information, providers should Expect Emotion and respond empathically—‘I wish I had better news’. When emotions are addressed, the next step is to find out what’s most important to the patient—Map out values. By eliciting what patients hope for and wish to avoid, the nephrology provider can Align with the values and Propose a plan based on these values [8]. This framework is summarized in Figure 1. Overview of the REMAP framework to guide goals of care discussions. Nephrology providers often view CC as synonymous with ‘no care’, further reinforcing the inertia toward dialysis as a default therapy. In fact, CC includes the basic elements of chronic kidney disease (CKD) care familiar to nephrology providers with the addition of domains to address symptom management and advance care planning. The difference between CC and standard CKD care is its focus on patient goals and prognosis rather than physiologic parameters. Thus, CC can be thought of as consisting of three domains: (i) modification of standard CKD care to emphasize quality of life, (ii) advance care planning and (iii) symptom management. Figure 2 shows how CC shifts the focus of standard CKD care to emphasize quality of life. For example, in standard CKD care, nephrology providers may aim to achieve patient-specific blood pressure targets. In CC, the emphasis shifts from a numerical target to avoidance of overly aggressive blood pressure lowering that may cause symptoms like fatigue or falls. The treatment focus accounts for the patient’s goals as well as overall prognosis. For patients with a prognosis of ≤6 months, medications are tailored to address symptom management only and agents focused on modification of physiologic parameters are often deprioritized. Framework of CC. SHPT, secondary hyperparathyroidism; CKD-MBD, chronic kidney disease mineral and bone disorder. aSee reference [9] for more detail. The second domain of CC is advance care planning, defined as a longitudinal process through which patients and providers outline preferences about current and future care [9]. CC requires that providers prepare patients for what to expect at end of life, including future services such as hospice for end of life care. Patients with kidney disease including those on CC experience a high symptom burden that can worsen toward the end of life. The third CC domain therefore involves active assessment and management of common symptoms. Nephrology providers may believe CC is best delivered by palliative care specialists. On the contrary, nephrology care is naturally set up to deliver patient-centered care. Nephrology providers already utilize an interdisciplinary team including nurses, dieticians, educators, social workers and pharmacists for CKD, dialysis and transplant care. With these experts and additional outside resources, nephrology providers can champion CC. One strategy to enhance CC within the nephrology clinic is to develop a process for CC as a team. For instance, CC can be incorporated into CKD modality education so that patients consider CC alongside dialysis options. By normalizing CC as a viable treatment option, the nephrology provider can extend the discussion to include relevant prognostic information and patient preferences. Similarly, the nephrology team can brainstorm ways to address symptom management and advance care planning within the existing workflow. For instance, medical assistants can incorporate basic advance care planning questions during patient intake such as, ‘Do you have a living will?’, ‘Who would you trust if you were too sick to speak for yourself?’ Additionally, symptom assessment tools exist to aid in the identification and management of symptom needs [10]. Nephrology providers should seek specialty services such as palliative care and hospice for complex symptom management, conflict within decision making and end of life care. Clinician hesitancy toward CC involves embracing and incorporating patient-centered care. The three CC principles presented here may assist nephrology providers in delivering CC. Further practice change, however, requires institutional and organizational support for CC. This may include extended clinic visits for goals of care conversations or the addition of resources such as social work or a dedicated CC nurse. Providers: https://www.kidneysupportivecare.org/For-Professio nals.aspx, http://ckmcare.com/ Patients: https://www.kidneysupportivecare.org/For-Patients- Families.aspx None declared.