Improving Medical Decision Making for Older Patients with End Stage Renal Disease

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A growing number of older patients are living with chronic kidney disease (CKD) due to advances in life- prolonging technologies and the aging of the population. As CKD advances towards end-stage renal disease (ESRD), even life-prolonging technologies cannot extend life indefinitely, especially for patients who have a poor prognosis and for whom decisions about medical interventions become particularly important. Consequently, older patients with advanced CKD need to communicate with their physicians about their preferences regarding CPR, dialysis and supportive kidney care (medical management of symptoms of advanced CKD without dialysis) in order to make crucial decisions impacting the length and quality of their lives. Communication surrounding medical decision making is formalized in Advance Care Planning (ACP), a process involving verbal or written information designed to inform patients of possible medical options including CPR, dialysis and supportive kidney care. Traditional ACP for patients with ESRD relies on ad hoc verbal descriptions of treatment options. This approach is limited because these options are difficult to envision. We have developed a video decision aid for reviewing CPR, dialysis and non-dialytic treatment preferences in ESRD. The tool, which is available in both English and Spanish, also allows patients to video record their preferences ("video declaration") and share their preferences with their clinicians and caregivers. The overall objective of this study is to conduct a multi-center randomized trial of the video intervention (vs. usual care) to test the hypothesis that the video better informs older persons with advanced CKD and poor prognosis of their treatment options and leads to more ACP documentation, informed decision making, and improved quality of life. We will compare ACP documentation after one year (or at time of death) among 600 patients aged 75 or older with advanced CKD and poor prognosis randomly assigned to either the video intervention or usual care (Aim 1). We will compare ESRD treatment preferences, decisional conflict, ACP engagement and conversations, and concordance of preferences stated after the video intervention or usual care with ESRD care delivery after one year (or at time of death) (Aim 2). We will explore the quality of life, longevity, and cost per Quality Adjusted Life Year (QALY) associated with patients' ESRD treatment decisions in the video vs. control groups (Aim 3). We will also conduct a qualitative assessment of the video declarations as well as barriers and facilitators for intervention success (Aims 4 and 5). ESRD in older patients involves complex decision making. It is imperative that we develop and evaluate early interventions to deliver more patient- focused care to this rapidly growing segment of the population. Using videos to enhance communication offers an opportunity to improve care of this vulnerable group of patients. Video is a practical, evidence-based, and innovative approach that has the potential to improve the quality of care provided to tens of thousands of older Americans.