NEPHROLOGISTS’ ATTITUDES AND PRACTICES REGARDING SHARED DECISION-MAKING, ADVANCE CARE PLANNING, AND PALLIATIVE CARE IN CHRONIC KIDNEY DISEASE

Shared decision-making (SDM), advance care planning (ACP), and palliative care (PC) are central to patient-centered nephrology care but remain unevenly implemented, especially in low- and middle-income countries. In India, where CKD prevalence is high, nephrologists face heavy clinical loads and complex value-laden decisions around dialysis, transplantation, and conservative management. This study examines Indian nephrologists’ attitudes and practices toward SDM, ACP, and PC.

We conducted a cross-sectional, web-based survey of all 2,462 members of the Indian Society of Nephrology (February-April 2025). The questionnaire that was used contained demographic questions and 28 Likert-scale items designed to capture attitudes and practices in SDM, ACP, and PC. Descriptive statistics summarized responses. Latent class analyses (poLCA in R) identified subgroups within each domain.

A total of 257 nephrologists responded (mean age 45; mean 13 years’ experience; 19% female; 26% government practice). The margin of error for the attitudinal and practice items ranged from 2.07% to 6.88%. Attitudinal support for SDM, ACP, and PC was strong. For instance, 90.5% endorsed the physician-patient-caregiver partnership. Regarding ACP, 96.7% stated that asking about patients’ values and preferences is essential, and almost all nephrologists favored collaboration between nephrology and palliative care (97.6%). However, practice did not entirely live up to the attitudes. While 91.6% told they often or always ensured that patients had adequate information about treatment choices, only 71.9% often or always discussed quality of life as a multidimensional reality. ACP actions were inconsistent too and PC referrals were infrequent.

LCA revealed two distinct clusters in each domain. In SDM, the majority (92.4%) were “Shared Decision-Makers,” who consistently endorsed partnership and comprehensive information-sharing, while a minority (7.6%) were “Paternalists,” who rejected that partnership and minimized the need for patient information despite claiming to provide it. In ACP, 61% were “ACP Supporters,” who were comfortable with end-of-life discussions, said to be proactive in initiating ACP during intercurrent illness, and committed to revisiting care plans. 39% were “Nephrologists Ambivalent to ACP,” who delayed ACP to later stages, expressed discomfort with advance directives, and doubted whether patients have the capacity to engage in ACP. In PC, 50.8% were “Active PC Advocates,” who supported earlier start of PC, and were more likely to refer patients, while 49.2% were “Passive PC Advocates,” who endorsed PC in principle but rarely referred patients. Cross-domain associations showed that ACP Supporters were more likely to practice in settings with PC services, and Active PC Advocates were more likely to have received PC training and to belong to the ACP Supporters.

Indian nephrologists strongly endorse SDM, ACP, and PC but attitudes do not always translate into practice. Availability of PC services and previous PC training not only predicted PC attitudes, but also nurtured openness to more proactive, value-aligned care. To bridge the gap between attitudes and practices, nephrology programs and health systems should invest in communication, PC and ACP training, and expand access to PC.