부산대학교 도서관

The survival benefits of dialysis in older people remain uncertain and are likely to come at considerable burden for many. Investigating older people's preferences for kidney care may inform the redesign of services that suit them better and improve outcomes important to them. This study aimed to understand and quantify the preferences of UK older comorbid people deciding between dialysis and non-dialysis conservative kidney management. Over-65-year-olds preparing for kidney failure participated in a mixed-methods study comprising qualitative work and a discrete choice experiment. Phase-1 involved 15 semi-structured interviews. Phase-2 included 26 think-aloud interviews as part of feasibility work for Phase-3, a choice experiment with 327 patients. Phase-1 interviewees appeared to understand treatment options incompletely and lacked support to make preference-sensitive decisions. Survival benefit appeared to be presumed with dialysis, driving a 'do or die' construct. Dialysis was expected to be burdensome. Those planning conservative kidney management anticipated a life on dialysis to be worse than death. Phase-2 informed the design and confirmed feasibility of a discrete choice experiment in this group. Four experimental attributes stemmed from Phase-1: survival; 'ability to do'; care location; and treatment frequency. Participants tended to prefer dialysis treatment despite other outcomes. Phase-3 participants were willing to relinquish 10-months' life expectancy to prevent their 'ability to do' halving. They needed to believe they would gain one year's survival benefit to accept conventional dialysis approaches; this increased to almost three years in unpartnered individuals who expected to become dependent. Three latent classes emerged with marked differences in preferred care location and willingness to trade survival to preserve the 'ability to do'. All were prone to a 'treatment is best' philosophy yet were willing to decline dialysis if the survival benefits were outweighed by treatment burdens. Older people favour longer lives, but only if their 'ability to do' is preserved and treatment burden is acceptable. This suggests that conservative kidney management would be more acceptable to patients if it were more familiar and better understood, and the relative benefits of dialysis communicated. Clinicians must establish what is important to patients when supporting them to decide how to prepare for kidney failure. Investment in services that offer greater choice, prioritise independence, and minimise travel for and intrusion from treatment would align with patients' preferences.