Original Investigation
Clinicians’ Perspectives on Advance Care Planning for Patients With CKD in Australia: An Interview Study

https://doi.org/10.1053/j.ajkd.2016.11.023Get rights and content

Background

Advance care planning (ACP) empowers patients to consider and communicate their current and future treatment goals. However, ACP is not widely implemented in chronic kidney disease (CKD) care settings. This study aims to describe clinicians’ beliefs, challenges, and perspectives of ACP in patients with CKD.

Study Design

Qualitative study.

Setting & Participants

Nephrologists (n = 20), nurses (n = 7), and social workers (n = 4) with a range of experience in facilitating ACP for patients with CKD across Australia.

Methodology

Semistructured interviews were digitally recorded and transcribed verbatim.

Analytical Approach

Transcripts were analyzed using thematic analysis.

Results

5 major themes were identified: facilitating informed decision making (avoiding preconceptions, conveying complete truths, focusing on supportive care, and synchronizing with evolving priorities), negotiating moral boundaries (contending with medical futility and respecting patient vs family autonomy), navigating vulnerable conversations (jeopardizing the therapeutic relationship, compromising professional confidence, emotionally invested, and enriching experiences), professional disempowerment (unsupportive culture, doubting logistical feasibility, and making uncertain judgments), and clarifying responsibilities (governing facilitation, managing tensions, and transforming multidisciplinary relationships).

Limitations

Some findings may be specific to the Australian context.

Conclusions

The tensions among themes reflect that ACP is paradoxically rewarding for clinicians because ACP empowers patients yet can expose personal and professional vulnerabilities. Clinicians believe that a more collaborative approach is needed, with increased efforts to identify the evolving and individualized needs and goals of patients with CKD. Models of ACP that address clinicians’ personal and professional vulnerabilities when initiating ACP may foster greater confidence and cultural acceptance of ACP in the CKD setting.

Section snippets

Methods

Study reporting is based on the Consolidated Criteria for Reporting Qualitative Health Research (COREQ).11

Participant Characteristics

In total, 20 nephrologists, 7 nurses, and 4 social workers (total N = 31; 70% response rate) participated. Three nurses and 1 social worker held a specific and primary role in conducting ACP conversations for patients with CKD. About half were women, the majority had more than 10 years of experience in nephrology, and most participants provided care to both non–dialysis-dependent and dialysis patients. Participant characteristics are provided in Table 1. Interview durations ranged from 24 to 69

Discussion

Clinicians caring for patients with CKD believed that ACP challenged the existing culture in nephrology by requiring a more collaborative approach to care and treatment decision making among clinicians, patients with CKD, and families. One challenge was that clinicians were expected to take a more individualized approach to patient care and explore each patient’s unique values and goals for the future. Clinicians found ACP conversations paradoxically rewarding because they empowered patients

Acknowledgements

Support: This study was supported by a competitive grant from Kidney Health Australia. Mr Sellars is supported by a University of Sydney Postgraduate Award. Dr Tong is supported by a National Health and Medical Research Council (NHMRC) Fellowship (1106716). Dr Morton is supported by an Australian NHMRC Fellowship (1054216). The funders had no role in study design; collection, analysis, and interpretation of data; writing the report; or the decision to submit the report for publication.

Financial

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