Table 2.
Comparison of nephrologists’ approaches to treatment decision making with older patients
| Themes | Paternalist | Informative (Patient Led) | Interpretive (Navigator) | Institutionalist |
|---|---|---|---|---|
| Patient autonomy | Views autonomy as assenting to health improvement; values trust over autonomy | Patient autonomy is most important; patient should choose and have control over medical care | Patient autonomy is integral to decision making | Views autonomy as assenting to objective values and institutional culture |
| Engagement and deliberation | ||||
| Neutral presentation of options | No | Yes | Yes | Often not |
| Solicitation of patient values and preferences | Related only to treatments presented | Always for all treatments | Always for all treatments | Related only to treatments presented |
| Offering explicit treatment recommendation | Always on the basis of clinical experience and perceived patient preferences | Only if patient requests a recommendation on the basis of expressed patient preferences | Always; incorporating patient-expressed preferences and clinical experience | Often; influenced by practice culture, incentives, and patient preferences |
| Influence of institutional norms | Weak | Weak | Moderate | Strong |
| Importance of specific clinical outcomes | Focus on survival, active therapies (e.g., dialysis initiation); omitting discussion of conservative management | Focus on process measures, autonomy, patient education, decision-making quality, patient-reported outcomes (quality of life) | Focus on shared decision making, patient education, patient-reported outcomes (quality of life) | Focus on survival, active therapies and quality of life, patient education of dialysis modalities |
| Perceived role of nephrologist | Promoting their perception of patient’s wellbeing irrespective of patient’s current preferences | Providing evidence-based education and implementing patient’s selected treatment | Clarifying and interpreting patient preferences, educating patients about options, recommending option, implementing patient selection | Promoting patient wellbeing and being a good steward of institutional resources and policies |