title: To dialyse or delay: a qualitative study of older New Zealanders' perceptions and experiences of decision-making, with stage 5 chronic kidney disease.
abstract: Issues related to renal replacement therapy in elderly people with end stage kidney disease (ESKD) are complex. There is inadequate empirical data related to: decision-making by older populations, treatment experiences, implications of dialysis treatment and treatment modality on quality of life, and how these link to expectations of ageing.
  
  
  
  Participants for this study were selected from a larger quantitative study of dialysis and predialysis patients aged 65 years or older recruited from three nephrology services across New Zealand. All participants had reached chronic kidney disease (CKD) stage 5 and had undergone dialysis education but had not started dialysis or recently started dialysis within the past 6 months.
  
  
  
  Serial qualitative interviews were undertaken to explore the decision-making processes and subsequent treatment experiences of patients with ESKD.Analytical approach: A framework method guided the iterative process of analysis. Decision-making codes were generated within NVivo software and then compared with the body of the interviews.
  
  
  
  Interviews were undertaken with 17 participants. We observed that decision-making was often a fluid process, rather than occurring at a single point in time, and was heavily influenced by perceptions of oneself as becoming old, social circumstances, life events and health status.
  
  
  
  This study focuses on participants' experiences of decision-making about treatment and does not include perspectives of their nephrologists or other members of the nephrology team.
  
  
  
  Older patients often delay dialysis as an act of self-efficacy. They often do not commit to a dialysis decision following predialysis education. Delaying decision-making and initiating dialysis were common. This was not seen by participants as a final decision about therapy. Predialysis care and education should be different for older patients, who will delay decision-making until the time of facing obvious uraemic symptoms, threatening blood tests or paternalistic guidance from their nephrologist.
  
  
  
  Australasian Clinical Trials Registry ACTRN 12611000024943; results.
authors.affiliation: School of Health Sciences, University of Canterbury, Christchurch, New Zealand.
authors.forename: Sarah
authors.initials: S
authors.lastname: Lovell
authors.affiliation: Department of Medicine, University of Otago, Dunedin, New Zealand.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Walker
authors.affiliation: Department of Medicine, University of Otago, Dunedin, New Zealand.
authors.forename: John B W
authors.initials: JB
authors.lastname: Schollum
authors.affiliation: Department of Renal Medicine, Counties Manukau Health, Auckland, New Zealand.|School of Medicine, University of Auckland, Auckland, New Zealand.|Medical Affairs, Baxter Healthcare (Asia) Pte Ltd, Singapore.
authors.forename: Mark R
authors.initials: MR
authors.lastname: Marshall
authors.affiliation: Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand.
authors.forename: Bronwen M
authors.initials: BM
authors.lastname: McNoe
authors.affiliation: Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand.
authors.forename: Sarah
authors.initials: S
authors.lastname: Derrett
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001294:Attitude to Health; D000066491:Clinical Decision-Making; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000523:psychology / Q000628:therapy*; D007902:Length of Stay; D008297:Male; D009520:New Zealand; D011788:Quality of Life; D006435:Renal Dialysis / Q000523:psychology*; D020377:Self Efficacy
keywords: Elderly; QUALITATIVE RESEARCH; decision-making