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Individualizing Patient Care through Education and Shared Decision Making

Patients with chronic kidney disease (CKD) often slide into default treatments and approaches. For instance, in the United States, they often start with in-center hemodialysis by default, when peritoneal dialysis could have been a much better fit. Many of these instances that involve patients sliding into unideal treatment plans could be avoided by proactive patient education and shared decision making (SDM) between the physician and patient.

On one end of the patient education scale is informed choice, a new model that helps patients make their own decisions about their care after physicians educate them on their choices. This practice is opposite of the historically used authoritative decision-making model in which physicians solely direct their patients’ treatment.  In between the two lies SDM, which creates a partnership between physician and patient in which neither party is singularly responsible for decisions. As such, SDM could play a valuable role in helping improve long-term outcomes for CKD patients.

In 2017, the Center for Medicare & Medicaid Innovations proposed testing an SDM consultation model in which the SDM practitioner would have an in-person discussion with the patient. The practitioner would:

  • Review individualized, available treatment options with the patient
  • Educate on treatment option pros and cons
  • Help the patient identify personal preferences related to treatment options
  • Listen to the patient and answer any questions regarding the treatment decision

The testing was recently was canceled, however, because an inadequate number of Accountable Care Organizations were interesting in participating.

To assist patients with making decisions, SDM often leverages a variety of educational aids, including written materials, computer-based tools and DVDs or videos. With these tools, patients and their families can better assess the benefits, risks and alternatives of their dialysis options before deciding whether to initiate either home or palliative dialysis or no dialysis at all. They also will better understand what various dialysis treatments entail, as well as how being on dialysis will affect all parties involved.

Nephrology practices that adopt SDM may realize a variety of positive outcomes, including:

  • Increased use of treatment options that may uniquely benefit each individual patient
  • Increased opportunities for patients to make informed health decisions
  • Limited unwarranted health care variations
  • Improved sustainability of the health care system

It cannot be over emphasized that in-center hemodialysis should not be the default option for all patients with advanced kidney failure. As the health care industry moves toward fully embracing patient-centered care, key leaders in the medical field and government must act to help make sure patients are receiving both the necessary education and support to assist them in making major health decisions. Doing so is imperative in demonstrating we uphold the Hippocratic Oath in our daily practice.

Martin Schreiber, MD

Martin Schreiber, MD

With nearly 40 years of experience in nephrology, Martin Schreiber, MD, serves as chief medical officer for DaVita Kidney Care's home modalities. Before this role, he worked primarily with Cleveland Clinic and held a number of key positions there, including member of the Board of Governors, chairman of the Department of Nephrology and Hypertension and director of home dialysis.