title: Clinicians' Perspectives on Advance Care Planning for Patients With CKD in Australia: An Interview Study.
abstract: BACKGROUND
  Advance care planning (ACP) empowers patients to consider and communicate their current and future treatment goals. However, ACP is not widely implemented in chronic kidney disease (CKD) care settings. This study aims to describe clinicians' beliefs, challenges, and perspectives of ACP in patients with CKD.
  
  
  METHODS
  Qualitative study.
  
  
  METHODS
  Nephrologists (n=20), nurses (n=7), and social workers (n=4) with a range of experience in facilitating ACP for patients with CKD across Australia.
  
  
  METHODS
  Semistructured interviews were digitally recorded and transcribed verbatim.
  
  
  METHODS
  Transcripts were analyzed using thematic analysis.
  
  
  RESULTS
  5 major themes were identified: facilitating informed decision making (avoiding preconceptions, conveying complete truths, focusing on supportive care, and synchronizing with evolving priorities), negotiating moral boundaries (contending with medical futility and respecting patient vs family autonomy), navigating vulnerable conversations (jeopardizing the therapeutic relationship, compromising professional confidence, emotionally invested, and enriching experiences), professional disempowerment (unsupportive culture, doubting logistical feasibility, and making uncertain judgments), and clarifying responsibilities (governing facilitation, managing tensions, and transforming multidisciplinary relationships).
  
  
  CONCLUSIONS
  Some findings may be specific to the Australian context.
  
  
  CONCLUSIONS
  The tensions among themes reflect that ACP is paradoxically rewarding for clinicians because ACP empowers patients yet can expose personal and professional vulnerabilities. Clinicians believe that a more collaborative approach is needed, with increased efforts to identify the evolving and individualized needs and goals of patients with CKD. Models of ACP that address clinicians' personal and professional vulnerabilities when initiating ACP may foster greater confidence and cultural acceptance of ACP in the CKD setting.
authors.affiliation: Sydney Medical School, The University of Sydney, Sydney, Australia.
authors.forename: Marcus
authors.initials: M
authors.lastname: Sellars
authors.affiliation: Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Australia.
authors.forename: Allison
authors.initials: A
authors.lastname: Tong
authors.affiliation: Improving Palliative Care through Clinical Trials (ImPaCCT) New South Wales, Australia; Faculty of Health, University of Technology Sydney (UTS), Australia.
authors.forename: Tim
authors.initials: T
authors.lastname: Luckett
authors.affiliation: NHMRC Clinical Trials Centre, The University of Sydney, Australia.
authors.forename: Rachael L
authors.initials: RL
authors.lastname: Morton
authors.affiliation: Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Renal Medicine, Royal North Shore Hospital, Australia.
authors.forename: Carol A
authors.initials: CA
authors.lastname: Pollock
authors.affiliation: NHMRC Clinical Trials Centre, The University of Sydney, Australia.
authors.forename: Lucy
authors.initials: L
authors.lastname: Spencer
authors.affiliation: Sydney Medical School, The University of Sydney, Sydney, Australia.
authors.forename: William
authors.initials: W
authors.lastname: Silvester
authors.affiliation: Sydney Medical School, The University of Sydney, Sydney, Australia; Improving Palliative Care through Clinical Trials (ImPaCCT) New South Wales, Australia; HammondCare Palliative & Supportive Care Service, Greenwich Hospital, Sydney, Australia. Electronic address: josephine.clayton@sydney.edu.au.
authors.forename: Josephine M
authors.initials: JM
authors.lastname: Clayton
mesh_terms: D000328:Adult; D032722:Advance Care Planning / Q000458:organization & administration*; D001291:Attitude of Health Personnel; D001315:Australia; D000066491:Clinical Decision-Making / Q000379:methods; D003657:Decision Making / Q000941:ethics*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011369:Professional-Patient Relations / Q000941:ethics*; D036301:Qualitative Research; D051436:Renal Insufficiency, Chronic / Q000523:psychology / Q000628:therapy; D013727:Terminal Care / Q000941:ethics / Q000379:methods / Q000523:psychology
keywords: ACP discussions; Chronic kidney disease (CKD); advance care planning (ACP); conservative care; doctor-patient communication; end-of-life; informed decision-making; interviews; medical futility; nephrology; nephrology training; patient preferences; semi-structured interviews; shared decision making; supportive care