The COVID-19 pandemic’s impact on treatment decision-making for older patients with kidney disease

The COVID-19 pandemic disrupted medical care for many individuals, including older patients with advanced chronic kidney disease (CKD). A recent study published in CJASN examined how shared decision-making—the process by which clinicians, patients, and their care partners work together to make decisions about treatments and care—was influenced by the uncertainty surrounding the evolving pandemic.

For the study, Keren Ladin, Ph.D., MSc (Tufts University) and her colleagues interviewed 76 adults (39 older patients with advanced CKD, 17 care partners, and 20 clinicians) from Boston, Portland (Maine), San Diego, and Chicago from August–December 2020.

The team found that clinicians perceived greater vulnerability among older patients with CKD and they more readily encouraged home-based modalities during the COVID-19 pandemic, but their discussions of vulnerability, advanced care planning, and conservative management remained limited. Lack of discussions of COVID-19–related risks, fewer education options, and inconsistent discussions of advanced care planning and conservative management left patients with unaddressed concerns and the need to navigate the emerging COVID-19 guidance on their own.

Despite heightened uncertainty, patient preferences for treatment modality (such as dialysis) remained stable, and most perceived their chosen modality to be the safest. Importantly, clinicians reported burnout caused by the pandemic, increased time demands, and workforce limitations.

“To improve shared decision-making during the pandemic and its aftermath, clinicians should promote and encourage conversations with patients who want to talk about COVID-19, with an emphasis on safety and quality-of-life, including the risks posed to them by COVID-19 and the impact of COVID-19 on treatment options. These discussions should present all options, including conservative management, and incorporate advanced care planning,” said Dr. Ladin. “Also, clinician burnout must be addressed with adequate resources and appropriate training.”

Study authors include Thalia Porteny, Ph.D., MSc, Kristina M. Gonzales, Kate E. Aufort, Sarah Levine, John B. Wong, MD, Tamara Isakova, MD, Dena E. Rifkin, MD, Elisa J. Gordon, Ph.D., MPH, Ana Rossi MD, Gary Di Perna, MD, Susan Koch-Weser, ScD, Daniel E. Weiner, MD, MS, and Keren Ladin, Ph.D., MSc.

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