Blog | Wednesday, May 29, 2013

QD: News Every Day--Dialysis patients more optimistic about outcomes than nephrologists

Dialysis patients are more optimistic about survival rates and receiving transplants than their doctors, who often don't offer a more realistic prognosis, a study found.

The result is that patients who become seriously ill may opt for life-sustaining care when palliative care is an option, another author wrote.

Patients undergoing hemodialysis have an annual mortality rate exceeding 20%, comparable to some types of cancer, researchers began. To compare the perceptions of hemodialysis patients and their nephrologists, actual survival rates, and to how patients' expectations influence their goals of care, researchers at two dialysis units in Boston conducted a medical record abstraction of 207 patients who underwent dialysis at any time from November 2010 through September 2011.

Researchers then conducted in-person interviews with 62 eligible patients whose predicted 1-year mortality was at least 20%, and then compared patients' and physicians' expectations about 1- and 5-year survival and transplant candidacy.

Results appeared online first on May 27 at JAMA Internal Medicine.

Of the 207 hemodialysis patients, 72.5% (n=80) had a predicted 1-year mortality of at least 20%. Of the eligible interviewees, 62 participated (response rate, 78%). Patients were significantly more optimistic than their nephrologists about 1- and 5-year survival (P less than .001 for both) and were more likely to think they were transplant candidates (37 [66%] vs 22 [39%]; P=.008).

Of the 81% of patients reporting a 90% chance or greater of being alive at 1 year, 18 (44%) preferred life-extending treatment even if it meant more discomfort, compared with 1 (9%) among patients reporting a lower chance of survival (P=.045). Actual survival was 93% at 1 year but decreased to 79% by 17 months and 56% by 23 months.

The authors wrote that clinicians should always find out a patient's preferences before sharing prognostic estimates.

Researchers wrote, "Perhaps of greater concern is our finding that nephrologists reported that, for 60% of patients, they would not provide any estimate of prognosis even if their patient insisted. This percentage of nondisclosure is higher than the percentage documented in the cancer literature and suggests that nephrologists may be even more reluctant to discuss prognosis with their hemodialysis patients than physicians caring for patients with cancer."

In an editorial, Mack Lipkin, Jr., MD, FACP, wrote that prospective research is needed to establish a basis for shared decision making, "[P]atients had unrealistic, favorable expectations about their likelihood of 5-year survival. As a result, should they become seriously ill, a significant percentage would opt for life-extending care, whereas those with more realistic expectations would choose comfort care. Disturbingly, few of their nephrologists had given them a prognosis, and several said they would not do so even if asked."