THE LIVED EXPERIENCES OF NEPHROLOGISTS DURING SHARED DECISION-MAKING FOR DIALYSIS INITIATION IN PATIENTS WITH ADVANCED CHRONIC KIDNEY DISEASE: A QUALITATIVE STUDY

Abstract

Initiating dialysis in patients with advanced chronic kidney disease (CKD) is a consequential decision involving medical, psychological, social, ethical, and financial considerations. Shared decision-making (SDM) provides a framework in which clinicians and patients collaborate to reach treatment decisions that integrate clinical evidence with patient values. However, nephrologists may encounter considerable challenges when facilitating these discussions, and their subjective experiences remain underexplored. This study aimed to explore the lived experiences of nephrologists involved in shared decision-making for dialysis initiation among patients with advanced CKD. A qualitative study with a phenomenological orientation was conducted using in-depth, semi-structured interviews with five consultant nephrologists recruited through purposive sampling from a tertiary care hospital. Interviews explored participants' experiences of discussing dialysis initiation, communication challenges, family involvement, ethical concerns, emotional experiences, factors influencing patient decisions, and perceived strategies for improving SDM. Data were analyzed using reflexive thematic analysis. Trustworthiness was supported through repeated engagement with the dataset, systematic comparison of coded extracts across participants, and maintenance of a reflexive stance. Seven themes were identified: (1) evolving toward patient-centred shared decision-making; (2) early and continuous communication as the foundation of decision-making; (3) bridging fear, misunderstanding, and communication barriers; (4) family involvement as support and source of tension; (5) balancing clinical guidance with patient autonomy; (6) emotional demands, empathy, and professional growth; and (7) systemic and resource constraints shaping meaningful choice. Participants described a shift from disease-centered communication toward greater attention to patient values, quality of life, and personal priorities. Early discussions were considered essential to allow patients and families time to understand treatment options before emergency dialysis became necessary. Fear, misconceptions, limited health literacy, language barriers, financial concerns, and unrealistic expectations complicated communication. Family members were reported as "potential sources of pressure," as well as "important sources of support. Ethical dilemmas arose for participants in cases where clinical recommendations differed from patient preferences, or when there were expected benefits to the treatment that were restricted. These conversations were challenging but were beneficial for developing empathy, patience, and professional development. However, patients were limited in the number of meaningful options available due to systemic factors, such as limited availability of peritoneal dialysis and transplantation, affordability and not enough consultation time. Dialysis initiation is a multi-faceted and ongoing process for nephrologists, not just a biomedical decision. Key elements of effective SDM are early communication, giving individual information, respecting patient autonomy, providing appropriate family involvement, allowing sufficient consultation time, ensuring treatment alternatives are accessible, and ensuring organizational support. The implications of these findings for communication training, service design and nephrology care for patients are discussed.