Understanding by older patients of dialysis and conservative management for chronic kidney failure

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License CC BY NC-ND 4.0 ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.BACKGROUND: Older adults with chronic kidney disease stage 5 may be offered a choice between dialysis and conservative management. Few studies have explored patients' reasons for choosing conservative management and none have compared the views of those who have chosen different treatments across renal units. STUDY DESIGN: Qualitative study with semistructured interviews. SETTINGS & PARTICIPANTS: Patients 75 years or older recruited from 9 renal units. Units were chosen to reflect variation in the scale of delivery of conservative management. METHODOLOGY: Semistructured interviews audiorecorded and transcribed verbatim. ANALYTICAL APPROACH: Data were analyzed using thematic analysis. RESULTS: 42 interviews were completed, 4 to 6 per renal unit. Patients were sampled from those receiving dialysis, those preparing for dialysis, and those choosing conservative management. 14 patients in each group were interviewed. Patients who had chosen different treatments held varying beliefs about what dialysis could offer. The information that patients reported receiving from clinical staff differed between units. Patients from units with a more established conservative management pathway were more aware of conservative management, less often believed that dialysis would guarantee longevity, and more often had discussed the future with staff. Some patients receiving conservative management reported that they would have dialysis if they became unwell in the future, indicating the conditional nature of their decision. LIMITATIONS: Recruitment of older adults with frailty and comorbid conditions was difficult and therefore transferability of findings to this population is limited. CONCLUSIONS: Older adults with chronic kidney disease stage 5 who have chosen different treatment options have contrasting beliefs about the likely outcomes of dialysis for those who are influenced by information provided by renal units. Supporting renal staff in discussing conservative management as a valid alternative to dialysis for a subset of patients will aid informed decision making. There is a need for better evidence about conservative management to support shared decision making for older people with chronic kidney failure.Peer reviewedFinal Published versio

Helping people discontinue long-term antidepressants: views of health professionals in UK primary care.

OBJECTIVE: The aims of this paper were to identify, characterise and explain clinician factors that shape decision-making around antidepressant discontinuation in UK primary care. DESIGN: Four focus groups and three interviews were conducted and analysed using thematic analysis. PARTICIPANTS: Twenty-one general practitioners (GPs), four GP assistants, seven nurses and six community mental health team workers and psychotherapists took part in focus groups and interviews. SETTING: Participants were recruited from seven primary care regions and two National Health Service Trusts providing community mental health services in the South of England. RESULTS: Participants highlighted a number of barriers and enablers to discussing discontinuation with patients. They held a range of views around responsibility, with some suggesting it was the responsibility of the health professional (HP) to broach the subject, and others suggesting responsibility rested with the patients. HPs were concerned about destabilising the current situation, discussed how continuity and knowing the patient facilitated discontinuation talks, and discussed how confidence in their professional skills and knowledge affected whether they elected to raise discontinuation in consultations. CONCLUSIONS: Findings indicate a need to consider support for HPs in the management of antidepressant medication and discussions of discontinuation in particular. They may also benefit from support around their fears of patient relapse and awareness of when and how to initiate discussions about discontinuation with their patients

A descriptive survey of cancer helplines in the United Kingdom: Who they are, the services offered, and the accessibility of those services

Abstract Background There are more than 1500 UK health helplines in operation, yet we have scant knowledge about the resources in place to support the seeking and delivering of cancer‐related telephone help and support. This research aimed to identify and describe cancer and cancerrelated helpline service provision: the number of helplines available, the variety of services provided, and the accessibility of those services. Method This study used online national questionnaire survey sent to 95 cancer and cancerrelated helplines in the United Kingdom. Results A total of 69 (73%) of 95 surveyed cancer and cancer‐related helplines completed the survey. Most helplines/organizations were registered charities, supported by donations; 73.5% of helplines had national coverage. Most helplines served all age‐groups, ethnic groups, and men and women. Only 13.4% had a number that was free from landlines and most mobile networks, and 56.6% could only be contacted during working hours. More than 50% of helplines reported no provisions for callers with additional needs, and 55% had no clinical staff available to callers. Ongoing support and training for helpline staff was available but variable. Conclusion Although cancer helplines in the United Kingdom offer reasonably broad coverage across the country, there are still potential barriers to accessibility. There are also opportunities to optimize the training of staff/volunteers across the sector. There are further prospects for helplines to enhance services and sustain appropriate and realistic quality standards

Patients’ and kidney care team’s perspectives of treatment burden and capacity in older people with chronic kidney disease: a qualitative study

Objective: Chronic kidney disease (CKD) is often a multimorbid condition and progression to more severe disease is commonly associated with increased management requirements, including lifestyle change, more medication, and greater clinician involvement. This study explored patients’ and kidney care team’s perspectives of the nature and extent of this workload (treatment burden) and factors that support capacity (the ability to manage health) for older individuals with CKD. Design: Qualitative semi-structured interview and focus group study Setting and Participants: Adults (aged 60+) with pre-dialysis CKD stages G3-5 (identified in two general practitioner surgeries and two renal clinics) and a multi-professional secondary kidney care team in the United Kingdom.Results: 29 individuals and 10 kidney team members were recruited. Treatment burden themes were: (a) understanding CKD, its treatment and consequences, (b) adhering to treatments and management, and (c) interacting with others (e.g.: clinicians) in the management of CKD. Capacity themes were: (a) personal attributes (e.g. optimism, pragmatism), (b) support network (family/friends, service providers), (c) financial capacity, environment (e.g.: geographical distance to unit) and life responsibilities (e.g.: caring for others). Patients reported poor provision of CKD information and lack of choice in treatment, whereas kidney care team members discussed health literacy issues. Patients reported having to withdraw from social activities and loss of employment due to CKD, which further impacted their capacity. Conclusion: Improved understanding of and measures to reduce the treatment burden (e.g. clear information, simplified medication, joined up care, free parking) associated with CKD in individuals as well as assessment of their capacity and interventions to improve capacity (social care, psychological support) will likely improve patient experience and their engagement with kidney care services

Assessing Consensus Between UK Renal Clinicians on Listing for Kidney Transplantation: A Modified Delphi Study.

BACKGROUND: It is well recognized that there is significant variation between centers in access to kidney transplantation. In the absence of high-grade evidence, it is unclear whether variation is due to patient case mix, other center factors, or individual clinician decisions. This study sought consensus between UK clinicians on factors that should influence access to kidney transplantation. METHODS: As part of the Access to Transplantation and Transplant Outcome Measures project, consultant nephrologists and transplant surgeons in 71 centers were invited to participate in a Delphi study involving 2 rounds. During rounds 1 and 2, participants rated their agreement to 29 statements covering 8 topics regarding kidney transplantation. A stakeholder meeting was used to discuss statements of interest after the 2 rounds. RESULTS: In total, 122 nephrologists and 16 transplant surgeons from 45 units participated in rounds 1 and 2. After 2 rounds, 12 of 29 statements reached consensus. Fifty people participated in the stakeholder meeting. After the stakeholder meeting, a further 4 statements reached agreement. Of the 8 topics covered, consensus was reached in 6: use of a transplant protocol, patient age, body mass index, patient compliance with treatment, cardiac workup, and use of multidisciplinary meetings. Consensus was not reached on screening for malignancy and use of peripheral Doppler studies. CONCLUSIONS: The Delphi process identified factors upon which clinicians agreed and areas where consensus could not be achieved. The findings should inform national guidelines to support decision making in the absence of high quality evidence and to guide areas that warrant future research

Harnessing Placebo Effects in Primary Care: Using the Person-Based Approach to Develop an Online Intervention to Enhance Practitioners' Communication of Clinical Empathy and Realistic Optimism During Consultations.

Background: Empathic communication and positive messages are important components of "placebo" effects and can improve patient outcomes, including pain. Communicating empathy and optimism to patients within consultations may also enhance the effects of verum, i.e., non-placebo, treatments. This is particularly relevant for osteoarthritis, which is common, costly and difficult to manage. Digital interventions can be effective tools for changing practitioner behavior. This paper describes the systematic planning, development and optimization of an online intervention-"Empathico"-to help primary healthcare practitioners enhance their communication of clinical empathy and realistic optimism during consultations. Methods: The Person-Based Approach to intervention development was used. This entailed integrating insights from placebo and behavior change theory and evidence, and conducting primary and secondary qualitative research. Systematic literature reviews identified barriers, facilitators, and promising methods for enhancing clinical empathy and realistic optimism. Qualitative studies explored practitioners' and patients' perspectives, initially on the communication of clinical empathy and realistic optimism and subsequently on different iterations of the Empathico intervention. Insights from the literature reviews, qualitative studies and public contributor input were integrated into a logic model, behavioral analysis and principles that guided intervention development and optimization. Results: The Empathico intervention comprises 7 sections: Introduction, Empathy, Optimism, Application of Empathico for Osteoarthritis, Reflection on my Consultations, Setting Goals and Further Resources. Iterative refinement of Empathico, using feedback from patients and practitioners, resulted in highly positive feedback and helped to (1) contextualize evidence-based recommendations from placebo studies within the complexities of primary healthcare consultations and (2) ensure the intervention addressed practitioners' and patients' concerns and priorities. Conclusions: We have developed an evidence-based, theoretically-grounded intervention that should enable practitioners to better harness placebo effects of communication in consultations. The extensive use of qualitative research throughout the development and optimization process ensured that Empathico is highly acceptable and meaningful to practitioners. This means that practitioners are more likely to engage with Empathico and make changes to enhance their communication of clinical empathy and realistic optimism in clinical practice. Empathico is now ready to be evaluated in a large-scale randomized trial to explore its impact on patient outcomes

Closing calls to a cancer helpline: expressions of caller satisfaction

ObjectiveThis study provides an alternative approach to assessing caller satisfaction focussing on how callers express their appreciation of the service provided during the call, as the calls draw to a close.MethodsConversation analysis is used to analyse 99 calls between callers and cancer specialist nurses on a leading cancer helpline in the UK.ResultsCaller satisfaction is expressed through upgraded forms of the appreciations through which callers begin to close the call. Dissatisfaction is conveyed in what are by comparison with expressions of satisfaction, downgraded forms which acknowledge but do not fully or enthusiastically appreciate the information/advice given. With latter calls, nurses begin to ‘re-open’ aspects of information/advice giving, thereby leading to more protracted call closings.ConclusionEndogenous indicators of caller satisfaction are displayed through callers’ upgraded appreciations in the closing moments of helpline calls. Difficulties in terminating calls (protracted by nurses re-opening information-giving etc.) arise when callers do not convey their satisfaction with the service provided.Practice implicationsAn understanding of endogenous indicators of satisfaction may benefit helpline organisations and further their understanding of effective call-handling, particularly through identifying the features common to those calls in which callers do not display their satisfaction with the call

The role of the health-care assistant in general practice

The role of the health-care assistant (HCA) has developed rapidly in general practice and has occurred on an ad hoc basis across the UK, with the precise role shaped by the requirements and culture of individual practices. Currently, there is no regulation of HCAs and little published material about the remit of the role. This study aimed to describe general practice colleagues' perceptions of the HCA role; identify key areas of inter-professional agreement and disagreement about the role; and describe the likely impact of these on the direction and development of HCAs. The study used a multiple-method qualitative study, using focus groups and semi-structured interviews and was set in general practices across one primary care trust. It featured uni-professional focus groups of practice nurses, HCAs and practice managers and interviews with GPs and practice managers. Transcribed material was analysed using constant comparison to derive robust themes. Participants focused on issues surrounding communication and teamwork and the fact that the individual nature of practices will affect the development of the HCA role. Questions regarding the development and structure of the HCA role were also broadly debated. The study concluded that the development of the HCA role in general practice is variable and the success of the role within a practice depends on good preparation for its future direction as well as the broad inclusion of team members in discussion and decision-making about the rol

The need to act versus reluctance to act: a qualitative study of primary care antidepressant prescribing for patients with common somatic conditions of uncertain cause

Background The National Institute for Clinical Excellence recently called on doctors to exercise more caution in prescribing antidepressants. Antidepressants are used in the management of patients with common somatic conditions of uncertain cause. The factors influencing the prescribing of antidepressants to this group of patients are not fully understood.Aim To explore general practitioners' and mental health professionals' perspectives on the use of antidepressants for patients with chronic fatigue syndrome (CFS), irritable bowel syndrome (IBS) and chronic back pain (CBP).Design of study A randomly selected sample of general practitioners and mental health practitioners in England were invited to participate in one of 16 focus group discussions. Clinical scenarios, including the use of antidepressants for patients with CFS, IBS and CBP, were discussed. Setting Meeting room, outside participants' work environment.Methods Purposive sample of six groups. Each comprised 9-13 participants (49 GPs and 15 mental health practitioners). Group talk was thematically analysed to identify their views on antidepressant prescribing.Results Two overarching and opposing themes emerged. The first was the need to act. Reasons for action included: lack of clear research evidence, desire to help patients, and a need for GPs to maintain their own self-worth. The second theme was a reluctance to act/prescribe antidepressants because of the potential for harm, their short-term effects and preference for somatic treatments for IBS and CBP.Conclusions The perception that action is preferable to inaction poses a barrier to effective clinical practice and can lead to internal conflict between practitioners' beliefs and actions