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.
Bio
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.
Email: mwachterman@partners.org