Coronavirus disease 2019 (COVID-19) disrupted medical care across health care settings for older patients with advanced CKD. Understanding how shared decision making for kidney treatment decisions was influenced by the uncertainty of an evolving pandemic can provide insights for supporting shared decision making through the current and future public health crises.

We performed thematic and narrative analyses of semistructured interviews with patients (CKD stages 4 and 5, age 70+), care partners, and clinicians from Boston, Portland (Maine), San Diego, and Chicago from August to December 2020.

We interviewed 76 participants (39 patients, 17 care partners, and 20 clinicians). Among patient participants, 13 (33%) patients identified as Black, and seven (18%) had initiated dialysis. Four themes with corresponding subthemes emerged related to treatment decision making and the COVID-19 pandemic: (1) adapting to changed educational and patient engagement practices (patient barriers to care and new opportunities for telemedicine); (2) reconceptualizing vulnerability (clinician awareness of illness severity increased and limited discussions of patient COVID-19 vulnerability); (3) embracing home-based dialysis but not conservative management (openness to home-based modalities and limited discussion of conservative management and advanced care planning); and (4) satisfaction and safety with treatment decisions despite conditions of uncertainty.

Although clinicians perceived greater vulnerability among older patients CKD and more readily encouraged home-based modalities during the COVID-19 pandemic, their discussions of vulnerability, advance care planning, and conservative management remained limited, suggesting areas for improvement. Clinicians reported burnout caused by the pandemic, increased time demands, and workforce limitations, whereas patients remained satisfied with their treatment choices despite uncertainty.

Decision Aid for Renal Therapy (DART), NCT03522740

2019 年冠状病毒病 (COVID-19) 扰乱了整个医疗机构对晚期 CKD 老年患者的医疗服务。了解不断变化的大流行的不确定性如何影响肾脏治疗决策的共同决策，可以为支持当前和未来公共卫生危机中的共同决策提供见解。

我们对 2020 年 8 月至 12 月期间来自波士顿、波特兰（缅因州）、圣地亚哥和芝加哥的患者（CKD 4 期和 5 期，70 岁以上）、护理伙伴和临床医生进行了半结构化访谈的主题和叙述分析。

我们采访了 76 名参与者（39 名患者、17 名护理伙伴和 20 名临床医生）。在患者参与者中，13 名 (33%) 患者被确定为黑人，其中 7 名 (18%) 已开始透析。出现了与治疗决策和 COVID-19 大流行相关的四个主题及其相应的子主题：（1）适应改变的教育和患者参与实践（患者护理障碍和远程医疗的新机会）；( 2 ) 重新概念化脆弱性（临床医生对疾病严重程度的认识提高，对患者 COVID-19 脆弱性的讨论有限）；( 3) 接受家庭透析，但不接受保守治疗（对家庭透析方式持开放态度，对保守治疗和高级护理计划的讨论有限）；( 4 ) 尽管存在不确定性，但治疗决策的满意度和安全性。

尽管临床医生认为老年 CKD 患者的脆弱性更大，并且在 COVID-19 大流行期间更愿意鼓励以家庭为基础的治疗方式，但他们对脆弱性、预先护理计划和保守治疗的讨论仍然有限，这表明有待改进的领域。临床医生报告说，大流行、时间需求增加和劳动力限制导致了倦怠，而尽管存在不确定性，患者仍然对他们的治疗选择感到满意。

肾脏治疗决策辅助 (DART)，NCT03522740