Photo Credit: iStock.com/Jacob Wackerhausen

A review finds gaps in patient-nephrologist communication in advanced kidney disease, including care planning and dialysis, and offers steps for improvement.

“Effective communication between physicians and patients has been shown to improve treatment adherence and build trust, facilitating constructive relationships,” researchers wrote in the Journal of Nephrology. “Good communication skills are crucial to patient care; however, many nephrologists do not receive adequate training regarding this matter. Data show that patients with chronic kidney disease stages 3–5 have varying levels of understanding about their disease and treatment options and the risks/benefits associated with each option. Additionally, individuals with advanced kidney failure report inadequate end-of-life discussions with their doctor.”

Mohadese Golsorkhi, MD, and colleagues conducted a narrative review to examine how patients with kidney failure perceive communication with clinicians. They focused on the importance of shared decision-making in clinical settings, advanced care planning in dialysis, and decisions around dialysis withdrawal, specifically in older adults. They also identified gaps in this area to help guide improvements in care.

Importance of Communication in Nephrology

The narrative review included 23 studies and identified “significant gaps in patient-physician communication, particularly in the domains of advanced care planning, shared decision-making, and dialysis withdrawal,” Dr. Golsorkhi and colleagues wrote.

First, they determined that patients often do not understand why patient-reported outcome measures (PROMs) are valuable. One study found that despite the importance of incorporating PROMs into care, many patients did not understand why they completed surveys about treatment outcomes, believing the surveys were for research purposes or simply routine protocol, rather than a measurement of their health. These patients also reported having difficulty quantifying their symptoms, and some expressed a desire to meet with a doctor before filling out PROMs forms in case they had questions. Others told interviewers that they thought PROMs had limited value because they believed these tools measured items that were not specific to their needs.

In their assessment of the use of empathy, the researchers highlighted a study of patients with diabetes and kidney disease. Empathy significantly improved patients’ “forgiveness,” or willingness to let go of anger and resentment, and improved health-related quality of life (QoL). This part of the review also assessed the impact of training programs on physician-patient communication in nephrology. A 4-hour training workshop conducted by experienced nephrologists and mental health professionals was deemed “essential and very useful” by 97% of participants, and all but one trainee noted that the course would impact their approach to clinical practice. Furthermore, 76% of trainees said the training had a “noticeable impact” in clinical settings. The training improved empathy scores among participants immediately after the course (P=0.005) and was sustained for several months after (P=0.04). Dr. Golsorkhi and colleagues noted that even a single training session “can have immediate and long-lasting effects” on clinical practices and improve nephrologists’ ability to see themselves in patients’ shoes.

The researchers noted that the field needs better-advanced care planning, particularly regarding palliative care. Only 20% of patients with kidney failure use hospice services, compared with 39.1% of those with congestive heart failure and 55% of those with cancer.

“It is advised that the nephrology team initiate the conversation about palliative care treatment,” Dr. Golsorkhi and colleagues wrote. “The extent to which these discussions are being carried out depends on the experience and comfort of the clinician. When physicians feel no longer comfortable continuing the discussion, managing refractory complications, or addressing cases of ‘futility,’ consultation with a palliative care specialist is recommended.”

Interventions To Improve Care

For each issue raised, the authors pointed to possible solutions. These focused on building communication skills with patients and discussing palliative care.

“This review features the multidimensional nature of patient-physician communication in nephrology, emphasizing the critical need for improved communication skills training, effective use of patient-reported outcome measures, and overcoming barriers to advanced care planning and shared decision-making,” Dr. Golsorkhi and colleagues wrote. “While progress has been made, moving forward necessitates a collaborative effort from healthcare professionals, researchers, and policymakers to fully realize the benefits of patient-centered communication in improving the care and QoL for patients with advanced kidney disease.”