Decision-Aid for Renal Therapy (DART), an interactive, online program for older adults, reduces conflict and regret over kidney failure treatment decisions, such as renal replacement therapy (RRT), investigators concluded.
In a trial (ClinicalTrials.gov: NCT03522740), Keren Ladin, PhD, MSc, of Tufts University in Medford, Massachusetts, and colleagues randomly assigned 363 patients from 8 clinics aged 70 years and older with stage 4-5 chronic kidney disease to DART or usual education. DART modules discussed kidney failure, peritoneal dialysis, hemodialysis, kidney transplant, medical management, and the decision-making process at a sixth-grade reading level, and asked patients questions about their preferences for RRT. DART content is available at www.goemmi.com/DART (code: TEST).
DART clarified treatment preferences and improved decision quality over the short term among older patients, the investigators reported in Annals of Internal Medicine. Patient knowledge significantly improved by a mean 9.0% and 9.4% more at 3 and 6 months, respectively, in the DART vs control group, with smaller improvements observed through 18 months.
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Overall, mean decisional conflict score declined by a significant 7.9 points more at 3 months and 8.5 points more at 6 months with DART compared with usual care. The subscales – uncertainty, informed, values clarity, and support – also significantly improved over 6 months with DART.
Patients “unsure” of their treatment preferences declined from 58% at baseline to 28%, 20%, 23%, and 14% at 3, 6, 12, and 18 months, respectively, with DART. The investigators found less decline in uncertainty in the usual care group: from 51% at baseline to 38%, 35%, 32%, and 18%, at the respective time points.
With DART, preferences for conservative management increased from 11.5% at baseline to 16.9% and 19.9% at 3 and 6 months, whereas it remained stable in the usual care group.
Trial participants were mostly White (78.1%), which is a limitation. Only 13.1% were Black, 5.0% were Asian, and 4.1% were Hispanic. DART was only available in English.
“Taken together, these findings underscore the promise of a replicable, scalable decision aid for preserving patient autonomy for critical decisions that determine how people live out their last stages of life,” Dr Ladin’s team wrote.
In an accompanying editorial, Fahad Saeed, MD, of the University of Rochester Medical Center in New York, and Jane O. Schell, MD, of the University of Pittsburgh School of Medicine in Pennsylvania, commented: “Ladin and colleagues have developed a decision support tool that has the potential to improve kidney therapy decision making for older people with advanced kidney disease. The true test will be whether [patient decision aids] will be made available to all older patients, including minorities and individuals with low health literacy, and otherwise achieve wide implementation, in contrast to current medical practice that typically advocates dialysis in all cases, regardless of the patient’s goals and best interests.”
Moving beyond dialysis as a default option will require building an infrastructure and culture that support shared decision making, they noted.
References
Ladin K, Tighiouart H, Bronzi O, et al. Digital decision aid may help older adults with CKD make better quality treatment decisions. Ann Intern Med. Published online December 19, 2022. doi:10.7326/M22-1543
Saeed F, Schell JO. Shared decision making for older adults: Time to move beyond dialysis as a default. Ann Intern Med. Published online December 19, 2022. doi:10.7326/M22-3431
