title: Understanding pre-dialysis modality decision-making: A meta-synthesis of qualitative studies.
abstract: OBJECTIVE
  This systematic review examined how people with chronic kidney disease make decisions about the type of dialysis modality to use. In particular, meta-synthesis was used to understand the process of patient decision-making and how aspects of context influenced these decisions. This topic is important because home-dialysis has economic and quality of life advantages for patients and society but is underutilized. To increase the use of home-based dialysis services a greater understanding is needed of how patients make dialysis modality decisions.
  
  
  METHODS
  Systematic review methods incorporating meta-synthesis were used.
  
  
  METHODS
  Seven databases were used for the search. Eligible studies were published qualitative research studies containing extractable data on decision-making about dialysis modality selection generated from patients with chronic kidney disease.
  
  
  METHODS
  A systematic review was conducted and the data were analyzed using meta-synthesis (also known as meta-ethnography) for qualitative research.
  
  
  RESULTS
  Sixteen studies were included (410 patients at various stages of chronic kidney disease). Across all the studies, decisions drew on patients' values and in the context of their situation and life. Common elements across patients' decisions were: (1) the illusion of choice--a matter of life or death, (2) minimization of the intrusiveness of dialysis on quality of life, autonomy, values, sense of self, and (3) decision-making in the context of wider knowledge and support.
  
  
  CONCLUSIONS
  Modality decisions are highly personal and strongly influenced by patient and family values, the context of their life, and a desire for minimal intrusiveness. There is a clear need for planned and timely discussions about modalities in which home-based dialysis is presented as a viable option. Professional support should focus on patient and family preparation, knowledge of different modalities and the lifestyle implications of different modality choices.
authors.affiliation: London Health Sciences Centre, Canada; University of Alberta, Canada. lori.harwood@lhsc.on.ca
authors.forename: Lori
authors.initials: L
authors.lastname: Harwood
authors.forename: Alexander M
authors.initials: AM
authors.lastname: Clark
mesh_terms: D000884:Anthropology, Cultural; D003657:Decision Making; D006437:Hemodialysis, Home / Q000523:psychology; D006801:Humans; D010342:Patient Acceptance of Health Care; D010353:Patient Education as Topic; D057240:Patient Preference; D010530:Peritoneal Dialysis; D036301:Qualitative Research; D051436:Renal Insufficiency, Chronic / Q000628:therapy*; D012944:Social Support