Dialysis modality selection: Why do we not truly share? A qualitative study of kidney physicians

Dialysis modality selection (DMS) is a key issue in end-stage kidney disease (ESKD). Despite high-quality evidence indicating comparable outcomes and potentially better quality of life with home dialysis and conservative kidney management (CKM), a larger-than-expected proportion of patients still ends up on in-centre haemodialysis (ICHD). Economic incentives focusing solely on dialysis reimbursement appear to be insufficient to change this pattern. Recent evidence points to unit culture as a major influencing factor for marked inter-centre variation in the uptake of alternative modalities. This study explored whether and how nephrologists’ attitudes towards shared decision-making (SDM) during DMS may reinforce a unit culture favouring ICHD over alternative options. We conducted an exploratory qualitative study using vignettes-based Q-methodology combined with think-aloud interviews to explore subjectivity, such as beliefs and opinions. Nephrologists were purposively selected using maximum-variation sampling based on age, gender, experience and home dialysis programme size, until no substantial new theme emerged. Interview transcripts were analysed using inductive thematic analysis, and reporting followed the COREQ guidelines. Twenty-five nephrologists from 15 centres participated. Inductive thematic analysis identified challenges to SDM at three main levels. 1/ Nephrologists’ perceptions of their own role, ranging from paternalistic over supportive and interpreter to informative and perceptions on the role of other stakeholders, including nurses, patient, GP and family. Whereas nurses were perceived as the main providers of pre-dialysis education, structured strategies to support nurses’ skills in SDM were lacking; 2/Perceived system-level barriers or facilitators at the meso and macro levels (unit or institutional local organisation, broader healthcare system, and societal expectations) such as limited availability of dedicated resources and services and insufficient financial incentives rewarding educational dimension of care; 3/ challenges inherent to the application of SDM in the context of DMS such as lack of interest in SDM and expertise in home dialysis and CKM with subsequent persistent prejudice. Our findings suggest that the interplay between clinicians‘ individual perspectives and perceived organisational factors may constrain the implementation of SDM in DMS, potentially contributing to the persistence of ICHD as the default treatment option. Perceptions of one’s own role and that of other stakeholders, together with challenges in implementing SDM in routine care—including limited engagement in SDM, persistent misconceptions regarding contraindications and inconsistent use of the available evidence, along with limited capacity to address system-level barriers at the micro-, meso-, and macro-levels—may compromise genuine shared-decision-making even before it starts by shaping the options and support services presented to patients. These findings suggest that changing the clinical culture surrounding dialysis-decision-making, rather than relying on individual motivation alone, may require a combination of financial and structural initiatives to improve quality of SDM; enhanced exposure of clinicians to alternative treatment modalities; and structural collaboration between units. This study was registered retrospectively on ClinicalTrials.gov on 23 January 2026 (NCT07364292).