Dialysis patients, doctors often out of sync on prognosis

For most kidney disease patients, nephrologists will not offer any prognostic estimates. As a consequence, most seriously ill patients on hemodialysis often are overly optimistic about their odds of survival, said a study published online May 27 in JAMA Internal Medicine, formerly the Archives of Internal Medicine.

The study of 62 kidney failure patients at two Boston-area dialysis centers found that 81% thought they had a better-than-90% chance of surviving a year. By contrast, the 14 nephrologists treating them shared that optimism for only a quarter of the patients.

The gap worsened for five-year prognoses. While just 6% of patients thought they had less than a 50% chance of dying within five years, nephrologists thought more than half had five-year survival odds of 40% or lower. Meanwhile, 66% of patients thought they were suitable candidates for kidney transplantation, but the nephrologists thought only 39% of them should be on the waiting list. And nephrologists would not provide any estimate of prognosis for 60% of patients, “even if their patients insisted,” said the study (link).

Other studies have found that nephrologists may be concerned about upsetting patients and giving them inaccurate survival times, though in this study the nephrologists’ estimates were much closer to the patients’ real death rates than the patients’ overly optimistic guesses. More than half of patients said that if their survival odds were significantly worse than they believed, they would want care to focus on pain relief rather than life extension.

“We may not be serving these patients as well as we could. These missed opportunities and misperceptions may actually be influencing patients’ goals of care,” said Melissa W. Wachterman, MD, MPH, the study’s lead author. “Giving seriously ill patients a realistic sense of their own illness can be important so they can make informed medical and life decisions moving forward.”