Table 4. Having Little to Offer Beyond Dialysis: Clinicians Believed That They Had Little More to Offer Patients Who Would Not Be Starting Dialysis.

Patient No.	Service	Exemplar Quotes From the Medical Record
Ending the therapeutic relationship
37	Nephrology clinic	States he “would rather die” than go on dialysis…will honor the patient’s wishes and continue to manage medically.
38	Nephrology clinic	Patient continues to refuse hemodialysis…since we cannot offer him any assistance from a renal standpoint other than hemodialysis at this stage of his disease, he will be discharged from renal clinic. Urged patient that should he change his mind about hemodialysis, to call us back to arrange this.
39	Primary care clinic	Offered to see the renal doctor, but he is not interested. He says he already saw that doctor, says the kidney doctor wanted to put him on dialysis. He does not want it.
Hospice as the only alternative
40	Inpatient medicine	Nephrology felt that hemodialysis was not a viable option secondary to the elevated pulmonary pressure.…The family was also not in favor of doing dialysis. Therefore, the team and family eventually came to the conclusion that there was nothing much that could be done for this gentleman, medically.
41	Cardiology clinic	Patient has near end-stage renal disease and is refusing to commit to beginning dialysis. Therefore, he is refusing to undergo further workup for his cardiac disease with a cardiac catheterization because of the fear of the risk of further kidney damage requiring dialysis.
42	Urgent care clinic	Hospice candidate, as patient has apparently refused dialysis.
43	Inpatient medicine	Patient’s son talked with patient’s brother and afterward was unsure of hospice…priority to talk to family in A.M. to address their concerns and strongly encourage hospice.
44	Inpatient social work	Spoke with patient who states he is familiar with hospice, “we had that for my wife,” and he agrees to hospice services.
45	Primary care clinic	He really ought to go into hospice and I tried to impress that on him…he really does not want to until he gets to the point where he really needs that kind of help.
46	Home-based primary care	[Daughter] wants to discuss hospice, desires referral stating she’s “no longer in denial”…veteran with generalized edema, dyspnea, somnolence, in fact, couldn’t wake him up this morning. Some difficulty breathing. She is in agreement with palliative care. She is aware provider encouraged hospice a week ago and her mother declined and vacillated regarding the referral.