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

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Journal Article
American Journal of Kidney Diseases, 2017, 70 (3), pp. 315 - 323
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© 2017 National Kidney Foundation, Inc. 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.
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