The National Palliative Care Research Center

Curing suffering through palliative care research.


Melissa Wachterman MD, MPH, MSc


Brigham and Women’s Hospital

Grant Year
Grant Term
Two years
Grant Type
Junior Faculty Career Development Award

Project Description
Understanding Trajectories of Decline in Older Adults with End-Stage Renal Disease and Improving Communication and Shared Decision Making About Treatment

Older adults are the fastest growing group of patients on dialysis for end-stage renal disease (ESRD).  Research shows that decision-making regarding initiation of dialysis is impaired by poor communication and lack of understanding about prognosis. Some small studies suggest that – relative to conservative management without dialysis – dialysis may be associated with longer life expectancy but possibly worse quality of life.  Yet little is known about what older adults can expect after initiating dialysis in terms of patient-centered outcomes such as pain, cognitive decline, and functional status.  Furthermore, even though the choice regarding dialysis initiation (particularly among older and sicker adults) involves a series of difficult trade-offs, there has been little research into patient, family, and provider perspectives on this decision-making process. 

In this context, we propose a study with the following two aims: 1) Define the trajectories of functional status, cognitive function, and pain that occur for adults 65 and older with ESRD after initiation of dialysis, compared to the trajectories of adults 65 and older not on dialysis; and 2) Explore perspectives of adults 65 and older, their families, and clinicians about decision-making regarding dialysis initiation (versus maximum conservative management).  The first project will be a quantitative analysis using nationally-representative longitudinal survey data from the Health and Retirement Study.  The second project will feature qualitative semi-structured interviews with patients, family members, and clinicians who are at different points in the decision-making process (prior to and after deciding about dialysis). The overall purpose of this career development award is to further our understanding of the decision-making process for older adults considering dialysis and to define patient-centered clinical trajectories after initiation of dialysis, which may help inform decision-making.  The ultimate goal is to lay the foundation for a subsequent intervention to improve communication and patient-centered decision-making in this area.


Melissa Wachterman, MD, MPH, MSc is a palliative care physician and Instructor of Medicine at Harvard Medical School. I hold joint appointments at Brigham and Women’s Hospital, the Boston VA, and Dana Farber Cancer Institute.  I conduct health services research focused on improving the quality of care for seriously-ill older adults with end-stage renal disease (ESRD).  As a 2014 NPCRC Career Development Award grantee, I will examine trajectories of patient-centered outcomes (cognitive and functional status and pain) for older adults on dialysis and explore decision-making about dialysis initiation from the perspectives of older adults with ESRD, their family caregivers, and their providers. The ultimate goal is to improve communication and patient-centered decision-making about dialysis initiation for this seriously-ill patient population.  I also have a strong interest in end-of-life care policy.