Navigating prognostic uncertainty with H.O.P.E. Caring for elderly patients with chronic kidney disease

Objective: To explore how older patients with chronic kidney disease (CKD) describe preferences for prognostic conversations. Methods: We used reflexive thematic analysis to analyze transcripts of semi-structured interviews with CKD patients. Participants were recruited between July 2017 and November 2020. Results: We identified three major themes: (1) “To Know or Not: Honoring Patient Choices” encapsulates how prognostic conversations should center on the patient's preferences. (2) “Earlier or Later: Embracing Diverse Perspectives on Timing” underscores how each patient holds a unique perspective on the timing of prognosis discussions, and (3) “Navigating Uncertainty: Humanistic Qualities That Empower Healthcare Professionals to Support their Patients through Prognostic Conversations”, highlights humanistic qualities that enable healthcare professionals to serve as sources of support for patients facing uncertainty during these conversations. Conclusion: Clinicians should proactively address the uncertainty of CKD by assessing patients’ informational needs, understanding their experiences and values, and gauging their openness to advance care planning. Tailoring communication and fostering a strong clinical rapport can enhance patient engagement and support difficult conversations throughout the disease trajectory. Practice implications: We propose a mnemonic to help clinicians consider and implement these themes as they empower their patients to make health care decisions in the face of uncertainty. HOPE: Honoring patients’ needs and wishes, Offering support, Promoting connections with careful and kind conversations and Exploring feelings and expectations. Clinicians should continue to strive for a strong human connection and provide prognostic information tailored to each patient's disease trajectory, needs and wishes.