Barriers and facilitators of conservative kidney management in older adults with chronic kidney failure: a qualitative study with nephrologists in Germany

Background Conservative kidney management (CKM) offers a treatment option for older adults with chronic kidney failure (CKF) and limited life expectancy. International evidence suggests that nephrologists face challenges in providing CKM. However, in Germany, in-depth research on this topic remains limited. Therefore, this study aims to explore barriers and facilitators experienced by nephrologists in CKM delivery to derive measures for improving its implementation. Methods Semi-structured interviews were conducted with nephrologists working in inpatient or outpatient settings in Berlin and the Federal State of Brandenburg, Germany in 2024. The Theoretical Domains Framework (TDF) guided data collection. The data were analyzed using qualitative content analysis. Results Eleven interviews were conducted. Nephrologists reported barriers and facilitators across ten TDF domains, overall. Barriers in delivering CKM were identified across nine TDF domains, such as knowledge (lack of CKM education), skills (insufficient shared-decision-making, SDM), social/professional role and identity (lack of clarification of nephrologists’ role in palliative care, divergence from professional role perception), beliefs about consequences (caregiver burden), reinforcement (unattractive reimbursement), environmental context and resources (insufficient intersectoral and interdisciplinary collaboration), and social influences ( relatives, societal expectations). Facilitators were also reported in nine TDF domains, for example knowledge (CKM training), reinforcement (adequate reimbursement), intentions (adjustment of treatment goals for older patients), environmental context and resources (improved interdisciplinary and intersectoral collaboration, patient decision aids), and social influences (treatment discussions with and without relatives). Conclusions CKM delivery is challenging at multiple levels. Our findings align with international barriers and complement previous national evidence by providing deeper insight into nephrologists’ attitudes, barriers within SDM, and the role of relatives. Improving CKM implementation requires multifaceted strategies, particularly system-level measures such as adequate reimbursement and CKM-related training to strengthen awareness and acceptance. In addition, structured SDM approaches and guidance on involving and considering relatives may be crucial to support CKM as a valid treatment option.