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Predialysis education: some cliffhangers
Transplantation
RenalReplacement
Therapy
Hemodialysis Peritoneal Dialysis
Options for End-Stage Renal Disease Patients
Integrated care 2010Follow up
Before dialysis
Hemodialysis
•In centre dialysis
•Satellite Dialysis
• home hemo
•Nocturnal dialysis
•Daily dialysis
Cre
atin
ine
Cle
aran
ce
(ml/
min
)
20
15
10
5
0Start of dialysis
Peritoneal dialysisTransplantation• Cadaveric
• living donor
• “Old for old”PD•APD
•CAPD
•Assisted PD
The Kidney Early Evaluation Program
Tamura et al, KI, 2013
What modality of dialysis should I choose?Dialysis modality selection:
Clinical advice from the European Renal Best Practice (ERBP) Advisory Board
www.european-renal-best-practice.org
What modality of dialysis should I choose?Dialysis modality selection:
Clinical advice from the European Renal Best Practice (ERBP) Advisory Board
www.european-renal-best-practice.org
2010
What modality of dialysis should I choose?Dialysis modality selection:
Clinical advice from the European Renal Best Practice (ERBP) Advisory Board
www.european-renal-best-practice.org
2010
Personalised Dialysis
– “informed patient choice”– Pre dialysis programs
Barriers at the provider level?
Odds of receiving PD as first line treatment
Komenda et al, submitted
Hingwala et al, NDT, 2013Patient survival
Hingwala et al, NDT, 2013Technique survival
Patient perspectives on informed decision-making surrounding dialysis initiation
Song et al, NDT, 2013
Sources of patient information
Ceapir survey, Van Biesen et al, submitted
Sources of patient information
Ceapir survey, Van Biesen et al, submitted
Patients that were involved with decision making were much more likely to be satisfied with their
treatment (OR 3.13 (95% CI 2.72-3.60)
Morton et al, BMJ, 2009
Patient Information: Predialysis
1. Patients do not recall having been informed at all2. Patients are informed “too late” i.e. in a state when they are
uraemic, desperate, depressed by their diagnosis….• Language too difficult• Irrelevant information• Too much information
3. Their is a “communication problem” between medical staff and patients on which topics/factors to value• Empathic listening• Motivational interviewing
4. Patients tend to make heuristic, not objective decisions• Danger of exposing them to other patients
Shared decison making
Shared decison making
1. Making the options clear2. Help the patient with making an informed choice
1. Value Clarification2. Elicit patient preferences3. Avoid bias by your own beliefs and values4. Suggest solutions that fit these values and preferences5. Facilitate decision making
Shared decison making
1. Making the options clear2. Help the patient with making an informed choice
1. Elicit patient preferences2. Suggest solutions that fit these preferences3. Facilitate decision makingIn
form
(but the information does not exist)
www.european-real-best-practice.org
(but the information does not exist)
www.european-real-best-practice.org
Is APD better than CAPD?
Relative risk CAPD vs APD
Mehrotra et al, KI 2009
Survival CAPD vs APD
Michels et al, cJASN, 2009
Survival CAPD vs APD
Badve et al, KI 2008
Survival fast transporters APD vs CAPD
Johnson et al, NDT, 2010
APD survival superior in fast transporters, but CAPD better in slow transporters
Incident patient vs 90-day Analyses
Quinn JASN 22:1534 2011
Probability ambiguity
complexity
CONTEXT
Shared decison making
1. Making the options clear2. Help the patient with making an informed choice
1. Value Clarification2. Elicit patient preferences3. Suggest solutions that fit these preferences4. Facilitate decision making
Info
rmDeliberate
Morton et al, BMJ, 2009
Morton et al, BMJ, 2009
Anchoring (+Halo effect)AttributionAvailability
Nephrology fellow
NephrologistHead nurse operating theatre
anesthesist
nutrition
Supervisor PD
Head nurseNephrology
Surgeon
Team management!!!
Approaches to Value Clarification/Preference Elicitation process:
•interactiveeg using sliding scales, ordering cards etc
1.assumptions: a.working "interactive" provides the patient with insight in his/her preferenceb.the patient has to make his preference clear to the other person
2.can be indirect (ask questions outside the question at end to obtain general preference) or direct3. always be careful to avoid decision regret and increased anxiety in patients4. always be careful to avoid "unbalanced" "coloured" phrasings
•non interactive eg video, dvd, booklets, patient stories, case scenarios: •this can be dangerous as they provide information in a linear fashion, and do not allow the "PE" step, which has to be made by the patient himself; •underlying assumption: patient will take the VC step while going through the information and will do the PE step later
Shared decison making
1. Making the options clear2. Help the patient with making an informed choice
1. Elicit patient preferences2. Suggest solutions that fit these preferences3. Facilitate decision makingIn
form Deliberate
Decide
Yodda: inform
Available on: www.european-renal-best-practice.org
Yodda: deliberateHaemodialysis Peritoneal Dialysis
Yodda: deliberate
Yodda: helping in decision
Yodda: helping in decision
“Shared Decision Making”