• Allison Tong, Katharine L Cheung, Sumi Sukumaran Nair, Manjula Kurella Tamura, Jonathan C Craig, and Wolfgang C Winkelmayer.
• Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia. Electronic address: allison.tong@sydney.edu.au.
• Am. J. Kidney Dis. 2014 Jun 1;63(6):913-27.

BackgroundAlthough dialysis prolongs life for patients with end-stage kidney disease, 20% of deaths in this population are preceded by dialysis therapy withdrawal. Recently, there has been more focus on conservative (nondialytic) care as a legitimate option, particularly for elderly patients. This study aims to describe patients' and caregivers' perspectives on conservative treatment and end-of-life care in chronic kidney disease (CKD).Study DesignSystematic review and thematic synthesis of qualitative studies.Setting & PopulationPatients with CKD and caregivers.Search Strategy & SourcesMEDLINE, Embase, PsycINFO, CINAHL, and reference lists were searched to May 2013.Analytical ApproachThematic synthesis was used to analyze the findings.Results26 studies involving more than 711 patients (non-dialysis dependent [n=41], hemodialysis [n=544], peritoneal dialysis [n=9]; unspecified dialysis modality [n=31], conservative management [n=86]) and 178 caregivers were included. We identified 5 themes: invasive suffering (bodily deterioration, loss of freedom and independence, unyielding fatigue and pain, resignation, treatment burden and harm, financial strain), personal vulnerability (imminence of death, misunderstanding and judgment, autonomy and dignity, medical abandonment, trust and safety), relational responsibility (being a burden, demonstrating loyalty, protecting others from grief), negotiating existential tensions (accepting natural course of life, disrupted aging, worthlessness, living on borrowed time, respecting sanctity of life, life satisfaction, preserving self-identity), and preparedness (decisional clarity, informational power, spirituality and hope).LimitationsNon-English articles were excluded; therefore, the transferability of findings to other populations is unclear.ConclusionsSome patients with CKD experience physical and psychosocial frailty and feel ambivalent about prolonging life. Some caregivers believe in providing relief from suffering, but are uncertain about making decisions regarding dialysis therapy initiation and discontinuation. We suggest that CKD management should encompass palliative care strategies that promote emotional resilience, sense of well-being, and self-value. Also, respectful and attentive communication may empower patients to convey their values and preferences about their own care.Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

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