Table 2.

Comparison of nephrologists’ approaches to treatment decision making with older patients

ThemesPaternalistInformative (Patient Led)Interpretive (Navigator)Institutionalist
Patient autonomyViews autonomy as assenting to health improvement; values trust over autonomyPatient autonomy is most important; patient should choose and have control over medical carePatient autonomy is integral to decision makingViews autonomy as assenting to objective values and institutional culture
Engagement and deliberation
 Neutral presentation of optionsNoYesYesOften not
 Solicitation of patient values and preferencesRelated only to treatments presentedAlways for all treatmentsAlways for all treatmentsRelated only to treatments presented
 Offering explicit treatment recommendationAlways on the basis of clinical experience and perceived patient preferencesOnly if patient requests a recommendation on the basis of expressed patient preferencesAlways; incorporating patient-expressed preferences and clinical experienceOften; influenced by practice culture, incentives, and patient preferences
Influence of institutional normsWeakWeakModerateStrong
Importance of specific clinical outcomesFocus on survival, active therapies (e.g., dialysis initiation); omitting discussion of conservative managementFocus 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 nephrologistPromoting their perception of patient’s wellbeing irrespective of patient’s current preferencesProviding evidence-based education and implementing patient’s selected treatmentClarifying and interpreting patient preferences, educating patients about options, recommending option, implementing patient selectionPromoting patient wellbeing and being a good steward of institutional resources and policies