Decision-making in nephrology: shared decision making?

Patient Education and Counseling 39 (2000) 81–89www.elsevier.com/ locate /pateducou

Decision-making in nephrology: shared decision making?

*Annique Lelie M.M.S., M.A.

Department of Ethics, Philosophy and History of Medicine, Faculty of Medical Sciences, Catholic University Nijmegen, P.O. Box 9101,6500 HB Nijmegen, The Netherlands

Received 10 January 1999; received in revised form 19 July 1999; accepted 26 July 1999

Abstract

Shared decision-making is considered an important ideal for physician–patient interaction. The ideal states thathealth-related values should be discussed together. It raises two questions: (a) for which decisions is the ideal of shareddecision-making relevant? (b) Which aspects of treatment should be discussed? The nephrological practice underconsideration in this article answers question (a) as follows: decisions about the type of dialysis are shared decisions, whiledecisions about the moment to start dialysis are medical decisions that should be taken by nephrologists. This situation canbe criticized as important health-related values play a role in decisions about starting dialysis. Question (b) is answered in thenephrological practice under consideration by discussing at least all important health-related aspects that raise uncertaintyabout its worth for a patient. This approach to question (b) is morally and practically defensible. 2000 Elsevier ScienceIreland Ltd. All rights reserved.

Keywords: Physician–patient communication; Nephrology; Shared decision-making

1. Introduction just reinforces the demand for well informed pa-tients, working together with their physicians in

Many physicians nowadays subscribe to forms of order to find the optimal treatment in the abundance‘shared decision-making’ with their patients as the of new drugs and therapies [3,4]. However, it is notideal way to come to treatment decisions. Shared yet clear what exactly is meant by ‘shared decision-decision making means that doctor and patient making’ [4]. From the perspective of physicians atdeliberate about the main aspects of treatment possi- least two questions arise: (a) for which decisions isbilities and finally come to a shared decision. Conse- the ideal of shared decision-making relevant? (b)quently, sharing a decision bridges the power gap When the ideal is deemed relevant, which aspects ofbetween physicians and patients [1,2]. The changing treatment should be discussed? Yet, medical practicenature of medical practice from acute to chronic care can not wait for answers. It must find ways to deal

with these topics. Central questions in this article,therefore, are: how do nephrologists deal with the*Tel.: 1 31-24-3613-104; fax: 1 31-24-3654-0254.

E-mail address: annique.lelie@alg / tf.wau.nl (A. Lelie) ideal of shared decision making and the questions it

0738-3991/00/$ – see front matter 2000 Elsevier Science Ireland Ltd. All rights reserved.PI I : S0738-3991( 99 )00093-2

82 A. Lelie / Patient Education and Counseling 39 (2000) 81 –89

raises, and how can their practice be evaluated? A decision-making, like Emanuel and co-workers statebrief sketch of the ideal of shared decision-making, that patients and physicians have to cooperate bywill be followed by the results of a study on informing each other and discussing all importantphysician–patient interaction in nephrology. It will health related values [1,15]. The aim of a discussionemerge that both ideal and practice can benefit from is ‘‘to help the patient determine and choose the bestthe comparison between the stated ideal and norms health-related values that can be realized in thein nephrological practice. clinical situation’’ [1]. A basic assumption of the

model is that patients’ preferences are not given buthave to be developed during a decision-making

2. The ideal of shared decision-making process. In the end, patient and physician agree onthe right treatment of the patient. This implies that

In 1956, Szasz and Hollender were among the first they share responsibility for the final decision [4,15].to recognize the need for a new model for the The defenders of the various shared decision-physician–patient relationship, especially for patients making models do disagree, however, on the advis-with chronic diseases. They proposed a model of ory task of the physician: Emanuel and Emanuel‘mutual participation’ in which the physician helps state that a physician should aim at moral persuasionthe patient to help himself [5]. Proposals such as this of the patient [1]. But Katz emphasizes the task ofwere, however, at first instance superseded by demo- physicians to help patients choose for themselvescratic developments stimulating autonomy of patients what is best instead of persuading them of what theand contractual approaches to the physician–patient doctor thinks is best [15]. Others are not explicit onrelationship. Only recently critics of ‘the autonomy this point; they use terms like ‘respect and guidance’paradigm’ or ‘contractualism’ and its legalistic as- [3].pects picked up the idea of mutual participation and So, many authors agree that the ideal has validitydeveloped it into ideals of shared decision-making and offers a good alternative to the engineering[3]. Especially one specific interpretation of contrac- model. However, some authors point out that thetualism, called the mechanistic, informative or en- ideal is difficult to fulfil [12,16]. Sometimes patientsgineering model of physician–patient interaction or physicians are not completely rational or theyelicited critical reactions [6]. This model stipulates refuse to spend time or money on shared decision-that a physician should inform a patient as adequate- making. What is more, Deber et al. concluded thatly as possible, but leave decision-making entirely to many patients prefer to leave the problem solvingthe patient [7]. A strong argument for this model was tasks — such as making a diagnosis and determiningprovided by studies showing that physicians are risks and probabilities — to their physicians, butoften poor judges of what their patients want [8,9]. only want to participate in choosing between alter-

The engineering model raised practical and moral native therapeutic options [14].problems, such as: how could one adequately andneutrally inform a patient? It was shown that the waypatients are informed highly influences the ‘choices’ 3. Methodsthey make [10,11]. Another issue was: why is thephysician not allowed to advise the patient what he The observations presented here are based onor she thinks best? Physicians may sometimes have a qualitative research on the interactions betweenbetter sense of probabilities and risks [12]. Further- nephrologists and patients discussing dialysis therapymore, it was shown that while patients might have a for kidney failure. They form part of a larger studyhigh desire for information they do not want to make on normative aspects in a nephrological practice. Thedecisions on their own [13,14]. Questions and criti- specialty of nephrology was chosen because itcisms like these paved the way for new models that concerns a practice area in which physicians oftenhad an ideal of doctors sharing a decision with have prolonged relationships and ample opportunitypatients in common. for shared decision-making with their chronically ill

Well-known defenders of an ideal of shared kidney patients. The setting is the nephrology out-

A. Lelie / Patient Education and Counseling 39 (2000) 81 –89 83

patient clinic of the Academic Hospital Nijmegen St. tion of the normativity of decision-making processesRadboud in The Netherlands. The nephrology de- concerning dialysis. It does not describe in exactpartment in this hospital consists of an out-patient numbers how often things happened, but what theclinic (about 3500 visits a year, 300–350 new underlying norms were. It also was not an aim of thispatients a year), a nephrological ward (18 beds) and study to check out how often practice deviated froma dialysis unit. About 35 hemodialysis patients are underlying ideals or norms.treated in this unit, a few patients are on home-hemodialysis and about 20 on CAPD (peritonealdialysis). The out-patient clinic is visited by patients 4. Resultswith a kidney disease, patients on peritoneal dialysisand patients with a functioning kidney transplant. In In the interactions with patients in end-stage renalNijmegen 100–125 kidney transplants are performed disease two central decision-making processes cameeach year. to the fore: decisions had to be taken about the type

Patients with a kidney disease whose kidney of dialysis therapy and about the moment to startfunction gradually deteriorated and who were ex- dialysis. The underlying normativity of those de-pected to start dialysis sooner or later were of cision-making processes is worked out in the follow-interest for this study. Most of these patients were ing. First, major normative aspects will be presented.grouped together on one morning per week for Subsequently, specific normative evaluations under-consultation by the dialysis resident. The consulta- lying the interactions with different categories oftions were attended. The methods involved observa- patients are discussed.tions and note taking during consultations and week-ly patient-discussions, informal questioning of the 4.1. Choice of therapyphysicians about the decision-making process imme-diately after the patient’s visit as well as the study of The Nijmegen nephrologists present the choice ofpatient charts, letters and other written material. dialysis as a choice the patient him or herself has toPatients were not interviewed. Informed consent was make, e.g., by explicitly mentioning that they shouldobtained through the patient’s physician, immedi- make their own choice (twice during the fieldwork)ately before consultation. None of the patients and and by emphasizing the importance of a goodphysicians refused participation. Fifty-nine interac- motivation (twice). To stimulate an informed choicetions between patients and nephrologists were thus the nephrologists try to find out what a patient’sobserved in which dialysis was discussed. Thirty considerations are by asking whether they have anypatients, four nephrology residents and one attending questions or by asking what they think. The nephro-nephrologist participated in the interactions. The logists prefer to commence the information processresults described in this paper were obtained in 1994, many months before the expected actual start of1995 and 1996. dialysis. Best is, in their view, if the information is

Identification of general practical rules, norms, and gradually conveyed and detailed, especially when itvalues underlying therapeutic decisions was the aim concerns the practical consequences of therapy.of this study. It focused on what the physicians Feelings, expectations and views of patients areconsider to be good usual care. Specific attention considered important for making a good choice. Ifwas paid to evaluative (i.e., normative) utterances time allows it, patients finally have to attend anduring conversation such as: ‘‘you should think extensive information session given by dialysisabout this’’ and ‘‘I should have discussed this nurses.earlier’’. Personal opinions of physicians were sepa- In 20 consultations the choice of dialysis therapyrated from more commonly held views by studying was discussed. In five consultations the nephrologistthe behaviour of different physicians in their contacts gave rather extensive information because the patientwith the same or similar patients and by comparing was still in the beginning of the information process.the answers of physicians on questions of the These discussions revealed that in the beginning ofobserver. The outcome of this fieldwork is a descrip- the information process the following aspects are


considered important. Two kinds of dialysis therapy related to three categories of patients: young andare available: peritoneal dialysis (CAPD) and otherwise healthy patients (13 patients), older orhemodialysis. CAPD should be performed by the (almost) terminally ill patients (4 patients) andpatient him- or herself, four times a day, taking half patients with additional medical problems besidesan hour each time. Hemodialysis should be done in their kidney disease (9 patients). Those approachesthe hospital usually three times a week, taking 3–4 h will be discussed below. Of course overlap betweeneach time. Hemodialysis treatment will be performed categories of patients exists which sometimes givesby a nurse. (The option of home-hemodialysis did difficulties in categorizing a particular patient. As anot have to be mentioned as this is only possible result 4 of the 30 patients could not adequately beafter following an intensive course during several categorized.months.)

The physician should assess the patient’s need for 4.2. Relatively young and otherwise healthy kidneyinformation and his or her capacity to process patientsinformation. The physician decides when the follow-ing aspects will be discussed. The most important In the process of discussing dialysis therapy withrisk of CAPD is peritonitis, which requires immedi- the group of young patients the major underlyingate treatment with antibiotics. A disadvantage of value assessment is usually not made explicit as thehemodialysis is that it can cause a hangover, espe- following typical example taken from the observa-cially during the first weeks of treatment. Patients tions illustrates:have to be informed about the small surgical pro-cedure that takes place before treatment can be Mr R. is 36 years old and known with astarted: for CAPD a catheter needs to be placed in gradually declining kidney function not yet neces-the belly and for hemodialysis a shunt in one of their sitating dialysis therapy. As a result of a surgicalarms has to be created. For CAPD the patient’s home procedure on a knee, however, his kidney functionusually has to be adapted a little (CAPD requires a rapidly decreases. When this appears from theseparate room and a good hygiene). This, however, is blood examinations his nephrologist calls him atpaid by the patient’s insurance company (mentioned home to tell him that they ‘‘have to think aboutonly once). (In The Netherlands dialysis treatment is dialysis’’. He proposes a visit to the dialysis unitalways covered by a patient’s insurance company, so for further information and explanation. Theaccording to the physicians this aspect does not have patient already knows a little about dialysis fromto be mentioned (during the fieldwork it was never earlier discussions with the nephrologist and sayspart of the information process). It is considered he has a slight preference for peritoneal dialysis.‘normal’ that patients do not have to pay fortreatments, especially not for in-hospital treatments. The central underlying value assessment in thisHowever, some patients think that adaptation of their physician–patient encounter is that life with thehouse for CAPD is not covered probably because it burden of dialysis is better than an early death. Thisdoes not fit with their concept of treatment.) evaluation, however, is not discussed. Instead, the

None of the patients were told that hemodialysis is physician says that they have to think about dialysis.more expensive than CAPD and that hemodialysis This means that the patient will die if he does notsometimes gives allocation problems as there are a follow the dialysis regime. The possibility not tolimited number of dialysis machines available. As a start dialysis is not discussed. The nephrologists andconsequence patients who choose hemodialysis probably most patients would not see this possibilitysometimes have to be treated in another hospital than as an alternative needing any consideration.they prefer. For young patients the nephrologists think CAPD

Comparison of the context of the information is the best choice of the existing options. Thisprocess — the way information was given and the preference is based on their own experiences withexact terms used — revealed that the physicians have patients and on medical literature indicating thatat least three typical ‘ideal’ approaches to patients quality of life of patients on CAPD is better than of


comparable patients on hemodialysis [17,18]. Now talk with the CAPD nurse. Such guidance of patientsand then the attending nephrologist tells his residents by physicians is allowed in this nephrological prac-that CAPD is preferred and stimulates them to let tice, but outright manipulation is considered a stepsuitable patients choose CAPD. All nephrology too far as the following utterance of a nephrologistresidents followed in this study let this preference reveals:play a role in the physician–patient communication. Physician (with dislike in his voice) about aThe following interaction illustrates this: patient who finally chose CAPD: ‘‘that man is not

merely advised, he has been outright manipulated!’’Mr T, 45 years old, regularly visits the out-

patient clinic. He was informed by another physi-4.3. Older and severely ill patientscian about CAPD and hemodialysis. His new

physician discusses dialysis with him in theWhen patients are older or are severely ill orfollowing way:

handicapped, the Nijmegen nephrologists think theyPhysician: have you made a choice yet?should explicitly discuss the option of not startingPatient: I think . . . (he raises his arm as a signdialysis. This was the case with 3 patients older thanthat he thinks about a shunt and thus80 years and 1 younger patient in a bad mental andhemodialysis).physical condition. In such situations the physiciansPhysician (surprisedly): Oh yes? We shoulddid discuss the basic value assessment involved,take some time to talk about that later.because they doubted whether life with dialysis isFollowing this, the physician performs a regu-better than death. The following case reveals manylar checkup which involves discussing complaints,aspects of the underlying normativity that usuallya physical examination and discussing furtherplays a role in cases of older or severely ill patients:(drug) treatment. At the end of the consultation

the physician returns to the subject of choosing adialysis therapy in the following way: Mr B is 86 years old when time has come ‘to

Physician: concerning CAPD, we should talk think about dialysis’, as his nephrologist states it.about that for a moment . . . and hemodialysis. Do He often visits the out-patient clinic with his son.you have questions about that? He is a kind and intelligent person. Then his

A short discussion follows, in which the physi- kidney function decreases rapidly. The nephro-cian answers questions about a shunt. Then she logist wants to talk about starting dialysis. At thissays there are no medical reasons not to choose time, however, Mr B does not understand much ofCAPD. She explains the advantages of CAPD the discussion. From the first question, he givesabove hemodialysis in the following way. With incoherent answers or starts to talk about anCAPD Mr. T ‘is his own master’. He can perform unrelated subject. Intoxication due to kidneythe therapy at work. It gives him ‘more freedom’. failure possibly contributes to his mental state.Another advantage is that CAPD is a gradual During the discussion with Mr B and his son theprocess, 24 h a day. A choice for hemodialysis physician phrases the following questions andmeans that he is stuck to three times a week and remarks:he can have a hangover from dialysis. At the end ‘‘I would like to talk with you about dialysis.of the discussion the physician proposes to have a You are not so young anymore . . . ’’talk with the CAPD nurse. ‘‘Actually, it should be done with everybody,

but with people of your age it is more important,The conversation with Mr T reveals several ways that they get acquainted with dialysis. Let’s see

in which the physician tries to influence the choice of whether you feel better. Of course, that is what ither patient. First, by being surprised and proposing is meant for.’’to discuss it again, second by phrasing a choice for ‘‘As a matter of fact, you have no choice,CAPD in attractive terms like ‘more freedom’ and because if you do nothing you will die’’‘being your own master’, and third, by proposing a ‘‘You would like to stay here for a while?’’ Mr


B says yes, but starts to talk about sleeping from diabetes and its complications and 3 patientstablets. had cardiac problems. CAPD is preferred for these

‘‘Of course we can always stop if things turn patients. One patient had a hemiparesis and could notout badly’’ perform his own therapy, so CAPD was not possible.

‘‘It’s possible that things happen and that you Contra-indications are divided by the nephro-want to stop. It’s good to think about that logists into two groups: absolute and relative. Pa-beforehand’’ tients with absolute contra-indications are told that

‘‘It is difficult to have a good talk about this only one type of dialysis therapy is suitable for them,now. You are too ill. We should discuss this again the other is not possible. For example, this is the casein 1 or 2 weeks’’ (when Mr B has probably for hemodialysis when no access to the bloodstreamimproved from dialysis). can be made or for CAPD when no CAPD catheter

After Mr B and his son have left, the nephro- can be placed. Relative contra-indications are alogist says to me that he should have initiated a higher risk for problems with one type of dialysisdiscussion about dialysis much earlier. (e.g., hemodialysis for patients with cardiac prob-

lems), a lower effectivity, or a higher chance offailure than usual (e.g., scars in the belly for CAPD).Although it immediately is clear that Mr B doesHowever, sometimes a relative contra-indication isnot understand the questions and remarks, his ne-‘absolutized’ in order to influence the decisionphrologist brings up many subjects. Why? Presumab-process as is the case with the following patient:ly, the physician wants to make clear to the son

which subjects should be thought about in cases ofelderly persons. He also reveals his criterium for Mr K, 61 years old, needs to start with dialysiscontinuation of dialysis once it is started, namely that very soon. He is referred to Nijmegen by anotherMr B must feel better. By this way, a later discussion hospital. As a result of surgical procedures in theabout continuation of dialysis therapy is normatively past he has many scars in his belly. CAPD willframed before one word is said. probably not be successful. In Nijmegen the

For older patients the nephrologists do not have a nephrologists refer the patient for investigation ofcommon preference for one type of dialysis therapy. his cardiac problems. His coronary arteries areMuch depends on the physicians assessment of a severely narrowed. This is a strong (but notpatient’s mental and physical abilities. For perform- absolute) contra-indication for hemodialysis. Aing CAPD minimal visual acuity is required. This little irritated one of the nephrologist explainsoften is a problem with patients with diabetic how the communication with the patient pro-nephropathy. Patients with dementia do not have the ceeded: ‘‘At first, they [in the other hospital] toldmental capacities to perform CAPD. Also the psy- him that CAPD was impossible, because of thechological make-up of older patients determines scars, now it is exactly the other way around. Thewhether a nephrologist has a preference. Relatively patient really does not understand it anymore.’’independent and otherwise healthy elderly patientswill be stimulated to choose CAPD, but older

‘Absolutization’ of contra-indications is consid-patients who are judged to need lots of social supportered wrong by the nephrologists. The severity of amight be better off with hemodialysis. The weakerproblem or risk should be explained to a patient.the preference of a physician for a type of dialysisAccording to the nephrologists, patients with relativetherapy the less he or she will try to influence thecontra-indications should be advised what to do, butdecision process.finally have to make their own choice.

4.4. Patients with additional medical problems4.5. The decision to start dialysis

Some medical problems are contra-indications forsome form of dialysis therapy. Nine patients could In 10 of the 59 consultations criteria for startingbe categorized in this group. Five patients suffered dialysis were explicitly discussed with either the


patient or the researcher after the patient’s visit. dialysis is started earlier in the disease process than aFrom the way the physicians discussed this, the few years ago.following norms are derived.

The major normative judgment underlying thedecision about starting dialysis is illustrated by the 5. Discussionfollowing dialogue:

In the medical practice studied here, shared de-cision-making partly plays a role in how physicians

Patient: when does it [dialysis] have to start?think decisions about dialysis should be taken.

Physician: that is very difficult to say . . . UnderAccording to the nephrologists a decision about a

5 or 6 we definitely have to start [5 or 6 refers toform of dialysis should be a shared decision. Patients

a measure of the kidney function]. Under 10 itare sometimes explicitly invited to participate in the

depends on how one feels and on whether thedecision process. Medical aspects and major conse-

blood results can be adequately controlled.quences for their lives (four times a day or threetimes a week, home or hospital, etc.) must be

The message of the physician in this dialogue is: discussed. Moral persuasion is allowed and evenblood examinations and symptoms of kidney failure viewed positively. Contrary to this, the decision toare important for determining the moment of start- start dialysis at a certain moment, although aning. The wishes, fears, preferences or convictions of important decision in nephrology, was not regardedthe patient are irrelevant for this decision. So, it is a as a decision that should be shared.medical decision that should be taken by the physi- In the decision about the right type of dialysiscian. None of the patients in this study participated therapy, not all important underlying value assess-in the decision-making about starting dialysis. ments are made explicit. An example of this is the

The physicians try to put off dialysis until they high value of life for relatively young and healthyfeel it can no longer be postponed without severe patients. What is more, discussions often have manycomplaints for or danger to the patient. This was normative aspects that are not discussed but functionexplicitly defended by 3 physicians. They consider as a normative framework for deliberations withdialysis to be a heavy burden for patients. A later different categories of patients. An example is thestart means a longer life without dialysis. As a one-sidedness of the information about dialysis; onlyconsequence the physical condition of patients usual- information about the personal consequences ofly improves when dialysis finally is started. This therapy for a patient’s life is revealed. The financialmight be beneficial to some patients as they become consequences for society or the shortage of organsbetter motivated to carry the heavy burden of are not discussed. Other examples of normativity aredialysis. This is a welcome but additional advantage mentioning the subjects (stopping dialysis) or criteriaof the policy to postpone dialysis as long as possible. (improved health after the start of dialysis) worthOf course dialysis is an expensive therapy. Although consideration or presenting one alternative in attrac-all physicians are aware of this aspect, only one of tive terms, like ‘more freedom’. Such framing ofthem explicitly mentioned this as an additional decisions is supported by other studies [20,21].reason to start dialysis as late as possible. However, Sullivan et al. have found in semi-structured inter-for diabetics it might be useful to start earlier as this views with 15 respirologists about intubation andprevents problems related to uremia, such as neuro- mechanical ventilation for end-stage COPD patientspathy. Severe uremic complaints such as itching, that all physicians advocated a shared decision-mak-nausea and tiredness also can be a reason to start ing approach, but 14 of them admitted that theyearlier than necessary on strict medical grounds. influence the deliberation process in order to guide

The question when to start dialysis is now and the patient’s choice [22].then discussed during a formal or informal meeting What do the results of this study of a nephro-with colleagues. The motive usually is a conclusion logical practice mean for the ideal of shared de-in the medical literature that an early start reduces cision-making? Two important questions will bemedical problems [19]. As a consequence, nowadays discussed.


5.1. For which decisions is the ideal of shared whether this really satisfies a need of patients anddecision-making relevant? physicians. The usual answer to the question which

underlying value assessments should be shared isThe choice of dialysis therapy was viewed as a that all important health-related values (or value

shared decision. The nephrologists are aware of assessments) involved in the decision should bemany non-medical aspects that play a role in this discussed with the patient [1]. Now, even this ideal isdecision. On the other hand, the nephrologists in this very difficult to fulfill as value assessments oftenstudy determined when dialysis had to start. The unconsciously influence a decision process. Somedecision to start dialysis is a ‘medical’ decision. important values and their assessments stay implicit,Personal experience of the author with a nephro- as we have seen in the information about dialysislogical practice in Canada, however, revealed that therapy and in the case of Mr R. Should thethe Canadian patients started earlier in their process physician be criticized for this? I don’t think so. It isof illness with dialysis, namely as soon as complaints unpractical and very difficult for physicians tolike itching, nausea and tiredness were bothersome become aware of all important underlying values[23]. In Canada an important motivation for an early especially if these values are not problematic. Thestart was reduction of the physical damages of a low following approach seems better.kidney function. The Dutch physicians in this study, In some situations the physicians are aware of thehowever, focused more on the heavy burden of importance of the values of life and death. This is thedialysis therapy. A later start is better as it means a case when patients are old or terminally ill. Forlonger life without dialysis and it possibly makes it example, Mr. B’s physician doubts whether life iseasier for patients to carry on with the therapy. So, better than death for him. Uncertainty about annot only medical–technical aspects but underlying underlying value assessment prompts his physicianmoral and psychological assessments of the quality to discuss it, not the mere presence of values. This isof life with and without dialysis, the importance of a better approach than the ideal of shared decision-the prevention of physical damage, and the way the making states. Those decisions and underlying valuephysicians think patients can be motivated for assessments are worth discussing that are possiblydialysis play a role in determining the moment to problematic for a patient. For example, not onlystart dialysis. Following the ideal of shared decision- decisions about starting dialysis but also their under-making these important underlying assessments — as lying values should be discussed, as the moment ofthey reflect health related values — should be starting dialysis has important consequences for thediscussed. physical and psychological condition of patients. The

An explanation for the gap between ideal and approach to share those value assessments that aremedical practice could be that the importance of possibly problematic might in practice turn out asmedical–technical aspects in the decision to start Deber’s suggestion to separate problem solving fromdialysis hides the non-medical aspects. No doubt that decision-making [14].medical expertise is required for the decision about An assumption of this approach to underlyingstarting dialysis. This, however, does not mean that values is that usually physician and patient assessphysicians should also automatically judge the im- many basic values similarly, e.g., the high apprecia-portance of the outcomes of physical examinations tion of life in the case of Mr R. Time and energy canand blood results. better be spent to extensively discuss decisions and

aspects of decisions about which views might differ,5.2. Which aspects of a decision should be e.g., the moment of starting dialysis, the financialdiscussed? consequences of different treatments, and the conse-

quences of a choice for society and other dialysisThe ideal of shared decision-making states that patients.

underlying value assessments should be discussed. In the nephrology practice studied persuasion ofShould physicians discuss all evaluative aspects? patients is allowed or, more correctly, it should playThis seems hardly possible as it will consume lots of a role in the decision process as long as patients aretime and energy. What is more, it can be doubted not coerced. This approach can be defended by the


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Decision-making in nephrology: shared decision making?