• WongSusan P YSPYKidney Research Institute, University of Washington, Seattle, WA; Health Services Research and Development Center, VA Puget Sound Health Care System, Seattle, WA; Division of Nephrology, University of Washington, Seattle, WA. Electronic ad, Saritha Boyapati, Ruth A Engelberg, Bjorg Thorsteinsdottir, Janelle S Taylor, and Ann M O'Hare.
• Kidney Research Institute, University of Washington, Seattle, WA; Health Services Research and Development Center, VA Puget Sound Health Care System, Seattle, WA; Division of Nephrology, University of Washington, Seattle, WA. Electronic address: spywong@uw.edu.
• Am. J. Kidney Dis. 2020 Feb 1; 75 (2): 167-176.

Rationale & ObjectiveIt is relatively unusual for US patients with advanced chronic kidney disease (CKD) to forgo initiation of maintenance dialysis. Our objective was to describe practice approaches of US nephrologists who have provided conservative care for members of this population.Study DesignQualitative study using semi-structured interviews.Setting & ParticipantsA national sample of 21 nephrologists experienced in caring for patients with advanced CKD who decided not to start dialysis.Analytical ApproachGrounded theory methods to identify dominant themes reflecting nephrologists' experiences with and approaches to conservative care for patients with advanced CKD.ResultsNephrologists who participated in this study were primarily from academic practices (n=14) and urban areas (n=15). Two prominent themes emerged from qualitative analysis reflecting nephrologists' experiences with and approaches to conservative care: (1) person-centered practices, which described a holistic approach to care that included basing treatment decisions on what mattered most to individual patients, framing dialysis as an explicit choice, being mindful of sources of bias in medical decision making, and being flexible to the changing needs, values, and preferences of patients; and (2) improvising a care infrastructure, which described the challenges of managing patients conservatively within health systems that are not optimally configured to support their needs. Participating nephrologists described cobbling together resources, assuming a range of different health care roles, preparing patients to navigate health systems in which initiation of dialysis served as a powerful default, and championing the principles of conservative care among their colleagues.LimitationsThe themes identified likely are not generalizable to most US nephrologists.ConclusionsInsights from a select group of US nephrologists who are early adopters of conservative care signal the need for a stronger cultural and health system commitment to building care models capable of supporting patients who choose to forgo dialysis.Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.

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