The “Deciding Not to Decide” Option Can Improve Older Adult Patient Care

Including the “Deciding Not to Decide” treatment option improves the standard of care for older adults with chronic kidney disease

People with chronic kidney disease over the age of 65 who are not candidates for transplant should be given the opportunity to not decide to begin dialysis in order to ensure informed decision-making, according to a new Rutgers paper.

The paper, published in the Journal of the American Society of Nephrology, discusses how physicians can improve care for older adults simply by taking more time to reflect and consider treatment options, rather than immediately defaulting to dialysis. Over 50 percent of those over 65 who are not candidates for a kidney transplant die within one year of starting treatment, according to studies.

“Advocacy for the ‘Deciding Not to Decide’ option in older patients is critically important to ensuring that patients and physicians have sufficient time to have conversations about treatment options that align with the quality-of-life patients seek,” says author Paul Duberstein, chair of the Department of Health Behavior and Society at the Rutgers School of Public Health. “‘Deciding Not to Decide’ strengthens patient-centered care through informed patient engagement, enabling patients to take the necessary time to consider all treatment options and their probable health outcomes, prior to hastily selecting a care plan. Patients can decide that they do not want to make a treatment decision at that time.” 

Their reasoning for advocacy also includes data showing that kidney function does not decline as quickly in older adults. Researchers say the “Deciding Not to Decide” option attempts to combat a patient’s perceived lack of choice in treatment and increase patient autonomy to ensure ethical consent. It would also place active medical management without dialysis on treatment lists as a viable option for many older adults.

“The ‘Deciding Not to Decide’ option, founded upon open and honest communication between physician and patient, offers patients flexibility in their treatment plans and we believe this alternative will be welcomed by both patients and physicians,” says Duberstein, who also oversees the Population Aging Concentration at the school.  “If conditions worsen, physicians and patients can reevaluate the treatment plan.  Nevertheless, initially including this option offers older adults with advanced chronic kidney disease additional time to decide how they want to live the remainder of their lives.”

Study co-authors include faculty from other collaborating institutions: Fahad Saeed and Kevin A. Fiscella (University of Rochester School of Medicine and Dentistry) and Alvin H. Moss (West Virginia University School of Medicine)