O45
SHARED DECISION MAKING FOR RENAL PATIENTS:
Implementing an Option Grid
Prichard, A, Thomas, N, Lloyd, A, Elwyn, G, acknowledging the Pre-Dialysis team
Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff
INTRODUCTION: Patients with impaired renal function face difficult decisions when choosing treatment
options. The challenge for the Pre-Dialysis team is to educate and involve our patients in deciding on their
options, which many find overwhelming. Some patients are limited by their co-existing medical conditions,
while others have all the options open to them. There is growing interest in shared decision making within the
renal community, and we hoped that our work would inform future practice. Patients are referred to the PreDialysis service in Stage 4-5 Chronic Kidney Disease (CKD), and are offered a home visit to discuss their
treatment options. This can be a lengthy visit, covering a lot of information. It is supported by written
information and an ongoing Pre-Dialysis programme, aiming for a smooth transition onto the chosen renal
replacement therapy (RRT).
METHOD: An Option Grid was developed which provided a comprehensive summary of the different
dialysis options, in a user-friendly format. This is a table on an A3 sheet of paper which is given to each
patient. It was organised according to 13 frequently asked questions, for example ‘How often will I need this
treatment?’ and ‘Can I still go on holiday?’ The effectiveness of this was evaluated using a Decision Quality
Measure (DQM) which was completed on two occasions; towards the end of the home visit, and then
approximately one month later.
RESULTS: During a five month period the Pre-Dialysis team identified 31 patients who had all the treatment
options open to them. 21 patients completed both DQM 1 and 2. Comparison of the results of DQM 1 and 2
demonstrated a clear improvement in the patients’ knowledge of RRT, and a clear shift from many patients
being undecided, to being able to make their choice. Using the DelibeRATE scale to demonstrate readiness to
decide, the DQM responses showed a dramatic change from patients being unsure or unable to judge which
treatment would suit them best, to over 80% of patients being able to decide and scoring positively in all
categories (ie. understanding the pros and cons of the treatments, and having given enough thought to the
treatment choices). Many patients noted that the meeting with the nurse was a very influential factor in
making their decision, emphasising the importance of getting the visit ‘right’. Another interesting outcome
was that patients often identified lifestyle as the most important consideration in their choice, which is not
always emphasised by our existing written information.
The Option Grid was well received by both patients and the Pre-Dialysis CKD Nurse Specialists as a useful
summary tool. This work also highlighted a large variation in patients’ understanding and their different
learning styles; with some taking in the information quickly and some needing to hear the information on
more than one occasion.
CONCLUSION:This project has highlighted the importance of using clear, consistent language, avoiding
medical jargon but also encouraging patients to use the correct terminology. For example, continuous
ambulatory peritoneal dialysis is often known as the dialysis with ‘the bags’, but referring to it as the dialysis
at home could easily be confused with home haemodialysis. Consequently, the Option Grid was modified and
re-worded several times before the final version was agreed upon. Following on from this, more work is now
being done to look at the factors which influence the patients’ decisions most, and what are the most important
considerations. We continuously asked for patient feedback as we developed our Option Grid, and were often
reminded that the patients’ priorities didn’t always match ours. While this work has helped us question our
practice and our use of language, more work is needed to understand how we can meet the patients’ priorities
more effectively.