title: Conservative care in Europe--nephrologists' experience with the decision not to start renal replacement therapy.
abstract: BACKGROUND
  For some patients with end-stage renal disease (ESRD), providing conservative care until death may be an acceptable alternative for renal replacement therapy (RRT). We aimed to estimate the occurrence of conservative care in Europe and evaluated opinions about which factors nephrologists consider important in their decision not to offer RRT.
  
  
  METHODS
  With a web-based survey sent to nephrologists in 11 European countries, we inquired how often RRT was not started in 2009 and how specific factors would influence the nephrologists' decision to provide conservative care. We compared subgroups by nephrologist and facility characteristics using chi-square tests and Mann-Whitney U tests.
  
  
  RESULTS
  We received 433 responses. Nephrologists decided to offer conservative care in 10% of their patients [interquartile range (IQR) 5-20%]. An additional 5% (IQR 2-10%) of the patients chose conservative care as they refused when nephrologists intended to start RRT. Patient preference (93%), severe clinical conditions (93%), vascular dementia (84%) and low physical functional status (75%) were considered extremely or quite important in the nephrologists' decision to provide conservative care. Nephrologists from countries with a low incidence of RRT, not-for-profit centres and public centres more often scored these factors as extremely or quite important than their counterparts from high-incidence countries, for-profit centres and private centres.
  
  
  CONCLUSIONS
  Nephrologists estimated conservative care was provided to up to 15% of their patients in 2009. The presence of severe clinical conditions, vascular dementia and a low physical functional status are important factors in the decision-making not to start RRT. Patient preference was considered as a very important factor, confirming the importance of extensive patient education and shared decision-making.
authors.affiliation: ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
authors.forename: Moniek W M
authors.initials: MW
authors.lastname: van de Luijtgaarden
authors.forename: Marlies
authors.initials: M
authors.lastname: Noordzij
authors.forename: Wim
authors.initials: W
authors.lastname: van Biesen
authors.forename: Cecile
authors.initials: C
authors.lastname: Couchoud
authors.forename: Giovanni
authors.initials: G
authors.lastname: Cancarini
authors.forename: Willem-Jan W
authors.initials: WJ
authors.lastname: Bos
authors.forename: Friedo W
authors.initials: FW
authors.lastname: Dekker
authors.forename: Jose L
authors.initials: JL
authors.lastname: Gorriz
authors.forename: Christos
authors.initials: C
authors.lastname: Iatrou
authors.forename: Christoph
authors.initials: C
authors.lastname: Wanner
authors.forename: Patrik
authors.initials: P
authors.lastname: Finne
authors.forename: Olivera
authors.initials: O
authors.lastname: Stojceva-Taneva
authors.forename: Svjetlana
authors.initials: S
authors.lastname: Cala
authors.forename: Vianda S
authors.initials: VS
authors.lastname: Stel
authors.forename: Charles
authors.initials: C
authors.lastname: Tomson
authors.forename: Kitty J
authors.initials: KJ
authors.lastname: Jager
mesh_terms: D000328:Adult; D000368:Aged; D003625:Data Collection; D003657:Decision Making; D005060:Europe; D005260:Female; D006801:Humans; D007674:Kidney Diseases / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009398:Nephrology / Q000639:trends*; D010820:Physicians / Q000639:trends*; D010818:Practice Patterns, Physicians'; D011379:Prognosis; D006435:Renal Dialysis; D017582:Renal Replacement Therapy / Q000639:trends*
keywords: conservative care; dialysis; end-stage renal disease; opinions; renal replacement therapy