Shared decision-making between patients and clinicians in vascular access determination for hemodialysis

Shared decision-making, which involves presenting choice, sharing personalized knowledge about options, and eliciting patients' values and preferences, is not only appropriate but encouraged under circumstances of uncertainty—that is, where no unequivocally superior choice exists. Vascular access (VA) decisions are thus "preference-sensitive," as they rely on the value individuals place on associated risks and benefits of each option.

As shared decision-making is a necessarily collaborative endeavor, it is imperative to examine processes by which patients and clinicians share information, preferences, and priorities about VA and arrive at mutually agreeable treatment plans.

A study recently published in the American Journal of Kidney Diseases (AJKD) highlights a series of critical decisions related to care goals and treatment strategies that necessarily precede the VA decision. Upon acceptance of kidney replacement therapy, patients were faced first with decisions related to transplantation and/or dialysis modality preferences, followed by VA selection once hemodialysis had been identified as the preferred or most appropriate treatment option. Upstream priorities about kidney replacement therapies influenced how patients and clinicians engaged in collaborative discussions about VA and perceived eligibility for a specific VA type.

As VA decisions were conditional on higher-order decisions, participants valued individualized information exchange at each decision point according to patients' readiness, priorities, and goals. Participants identified several opportunities to re-visit VA decisions after hemodialysis initiation, suggesting that shared decision-making should not be a singular occurrence and that the VA decision is not necessarily final or immutable. This was important particularly under circumstances where VA shared decision-making was undermined and hemodialysis initiation took place via a catheter as the only accessible, timely option.