Search

Objective: To outline the evidence for conservative care, including both assessment and management options, for urinary incontinence in women., Intended Users: Relevant primary care providers and medical specialists including but not limited to physicians, nurses, midwives, and pelvic health physiotherapists., Target Population: Women (>18 years of age) with urinary incontinence., Options: Assessment options include gathering of a detailed history, physical examination, laboratory analysis, urodynamic evaluation, and cystoscopy. Conservative management options include lifestyle management, pelvic floor muscle training, behavioural management, and mechanical devices., Outcomes: To provide an evaluation-based summary of current available evidence concerning efficacy of conservative care (assessment and management) strategies for urinary incontinence in women., Evidence: The Cochrane Library and Medline (2013-2018) were searched to find articles related to conservative care of urinary incontinence in women (>18 years). Articles were appraised, and the collective evidence was graded., Validation Methods: The evidence obtained was reviewed and evaluated by the Society of Obstetricians and Gynaecologists of Canada (SOGC) Urogynecology Committee under the leadership of the principal authors. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework., Benefits, Harms, and Costs: Evidence for the efficacy of conservative care (assessment and management) options for women with urinary incontinence is strong. Furthermore, these options carry minimal or no harm and confer an established cost benefit., Guideline Update: This SOGC Clinical Practice Guideline will be automatically reviewed 5 years after publication., Summary Statements: RECOMMENDATIONS., (Copyright © 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Rationale & Objective: It is relatively unusual for US patients with advanced chronic kidney disease (CKD) to forgo initiation of maintenance dialysis. Our objective was to describe practice approaches of US nephrologists who have provided conservative care for members of this population., Study Design: Qualitative study using semi-structured interviews., Setting & Participants: A national sample of 21 nephrologists experienced in caring for patients with advanced CKD who decided not to start dialysis., Analytical Approach: Grounded theory methods to identify dominant themes reflecting nephrologists' experiences with and approaches to conservative care for patients with advanced CKD., Results: Nephrologists who participated in this study were primarily from academic practices (n=14) and urban areas (n=15). Two prominent themes emerged from qualitative analysis reflecting nephrologists' experiences with and approaches to conservative care: (1) person-centered practices, which described a holistic approach to care that included basing treatment decisions on what mattered most to individual patients, framing dialysis as an explicit choice, being mindful of sources of bias in medical decision making, and being flexible to the changing needs, values, and preferences of patients; and (2) improvising a care infrastructure, which described the challenges of managing patients conservatively within health systems that are not optimally configured to support their needs. Participating nephrologists described cobbling together resources, assuming a range of different health care roles, preparing patients to navigate health systems in which initiation of dialysis served as a powerful default, and championing the principles of conservative care among their colleagues., Limitations: The themes identified likely are not generalizable to most US nephrologists., Conclusions: Insights from a select group of US nephrologists who are early adopters of conservative care signal the need for a stronger cultural and health system commitment to building care models capable of supporting patients who choose to forgo dialysis., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

This Core Curriculum article models a person-centered approach to care for older adults with kidney disease. We provide background information on the principles of person-centered care and outline ways in which this approach contrasts with the more disease-based approaches that dominate current medical education and practice. Using hypothetical cases, we discuss 3 clinical scenarios that arise commonly when caring for older adults with kidney disease: (1) a moderate reduction in estimated glomerular filtration rate, (2) new-onset nephrotic-range proteinuria, and (3) the prospect of starting dialysis. For each scenario, we summarize relevant available evidence and model what a person-centered approach might look like. In discussing each scenario, we highlight: (1) the considerable heterogeneity in clinical presentation, circumstances, priorities, and values that exist among older adults with kidney disease; (2) the importance of interpreting available evidence and clinical practice guidelines in the context of what is relevant to each patient; (3) methods for grounding discussions about care and treatment options in the realities of each patient's situation and what is most meaningful to them; and (4) the importance of setting aside one's own biases and practice style to ensure that patients' own values and goals guide their care., (Published by Elsevier Inc.)

To date, it is important to know more about the population of CKD stage 5 patients in order to better understand the practices of access to renal replacement therapy (RRT) or conservative treatment and to anticipate future needs. In April 2015, at the instigation of the Scientific Committee of REIN, a working group was formed to reflect on the opportunity and feasibility of a data collection on these patients. Between September 2017 and March 2018, 21 participating centers included 390 patients over a period of at least one month. The data collected included the patient's living conditions, level of study, mode of referral, clinical data and the therapeutic project. The median age at baseline was 71.4years (IQR: 58.4-80.4), 39.9% were diabetic. The median eGFR was 12mL/min/1.73m 2 (IQR: 9-14). At inclusion, 77% of the patients were already followed in nephrology, 11% had been referred by a general practitioner. For the majority of patients included (81%), there was a RRT project. In 10% of cases, there was a project of conservative care, in 5% of cases the project was not yet decided and in 7% the project had not been yet discussed. At the latest news (median time 4.0months), 35% of patients were dialyzed, 9 (2%) have been pre-emptively transplanted, 25 (6%) died, 210 (54%) were still with a CKD stage 5. Our pilot study has shown the feasibility and interest of setting up such a data collection. Such a registry will provide important public health information regarding the demographic of nephrologists and advanced practices nurses. At the local level, this information will help the department to organize themselves to set-up pre-RRT information, implementation of care pathway nurses and multidisciplinary meetings for difficult cases. However, our pilot study shows that to ensure the completeness of the collection, the tracking upstream or downstream of nephrology consultations for eligible patients is essential and therefore requires dedicated human time on site., (Copyright © 2019 Société francophone de néphrologie, dialyse et transplantation. Published by Elsevier Masson SAS. All rights reserved.)

Knee tendinopathies account for a large number of sports dropping, especially in sports requesting jumps and running. There is actually no consensus about the management of those injuries. Nevertheless, new therapies may offer possibilities to the non-responding ones. This review aims to actualise the treatment of knee tendinopathy, to discuss the most recent forms of treatment and their clinical use, limited by our current knowledge of the disease.

Background and Objectives: A geriatric assessment (GA) is a structural method for identifying frail patients. The relation of GA findings and risk of death in end-stage kidney disease (ESKD) is not known. The objective of the GA in OLder patients starting Dialysis Study was to assess the association of GA at dialysis initiation with early mortality and hospitalization., Design, Setting, Participants, and Measurements: Patients ≥65 years old were included just prior to dialysis initiation. All participants underwent a GA, including assessment of (instrumental) activities of daily living (ADL), mobility, cognition, mood, nutrition, and comorbidity. In addition, a frailty screening (Fried Frailty Index, [FFI]) was applied. Outcome measures were 6- and 12-month mortality, and 6-month hospitalization. Associations with mortality were assessed with cox-regression adjusting for age, sex, comorbidity burden, smoking, residual kidney function and dialysis modality. Associations with hospitalization were assessed with logistic regression, adjusting for relevant confounders., Results: In all, 192 patients were included, mean age 75 ± 7 years, of whom 48% had ≥3 geriatric impairments and were considered frail. The FFI screening resulted in 46% frail patients. Mortality rate was 8 and 15% at 6- and 12-months after enrolment, and transplantation rate was 2 and 4% respectively. Twelve-month mortality risk was higher in patients with ≥3 impairments (hazard ratio [HR] 2.97 [95% CI 1.19-7.45]) compared to less impaired patients. FFI frail patients had a higher risk of 12-month mortality (HR 7.22 [95% CI 2.47-21.13]) and hospitalization (OR 1.93 [95% CI 1.00-3.72]) compared to fit patients. Malnutrition was associated with 12-month mortality, while impaired ADL and depressive symptoms were associated with 12-month mortality and hospitalization., Conclusions: Frailty as assessed by a GA is related to mortality in elderly patients with ESKD. Individual components of the GA are related to both mortality and hospitalization. As the GA allows for distinguishing between frail and fit patients initiating dialysis, it is potentially of added value in the decision-making process concerning dialysis initiation., (© 2019 The Author(s) Published by S. Karger AG, Basel.)

Background: Little is known about patterns of end-of-life care for patients with advanced kidney disease not treated with maintenance dialysis., Study Design: Case series., Setting & Participants: A sample of 14,071 patients with sustained estimated glomerular filtration rates < 15mL/min/1.73m 2 treated in the US Veterans Affairs health care system who died during 2000 to 2011. Before death, 12,756 of these patients had been treated with dialysis, 503 had been discussing and/or preparing for dialysis therapy, and for 812, there had been a decision not to pursue dialysis therapy., Outcomes: Hospitalization and receipt of an intensive procedure during the final month of life, in-hospital death, and palliative care consultation and hospice enrollment before death., Results: Compared with decedents treated with dialysis, those for whom a decision not to pursue dialysis therapy had been made were less often hospitalized (57.3% vs 76.8%; OR, 0.40 [95% CI, 0.34-0.46]), less often the recipient of an intensive procedure (3.5% vs 24.6%; OR, 0.15 [95% CI, 0.10-0.22]), more often the recipient of a palliative care consultation (52.6% vs 21.6%; OR, 4.19 [95% CI, 3.58-4.90]), more often used hospice services (38.7% vs 18.2%; OR, 3.32 [95% CI, 2.83-3.89]), and died less frequently in a hospital (41.4% vs 57.3%; OR, 0.78 [95% CI, 0.74-0.82]). Hospitalization (55.5%; OR, 0.39 [95% CI, 0.32-0.46]), receipt of an intensive procedure (13.7%; OR, 0.60 [95% CI, 0.46-0.77]), and in-hospital death (39.0%; OR, 0.47 [95% CI, 0.39-0.56]) were also less common among decedents who had been discussing and/or preparing for dialysis therapy, but their use of palliative care and hospice services was similar., Limitations: Findings may not be generalizable to groups not well represented in the Veterans Affairs health care system., Conclusions: Among decedents, patients not treated with dialysis before death received less intensive patterns of end-of-life care than those treated with dialysis. Decedents for whom there had been a decision not to pursue dialysis therapy before death were more likely to receive palliative care and hospice., (Published by Elsevier Inc.)

Aim: To compare the efficacy and safety of total disc replacement, lumbar fusion, and conservative care in the treatment of single-level lumbar degenerative disc disease (DDD)., Materials & Methods: A network meta-analysis was conducted to determine the relative impact of lumbar DDD therapies on Oswestry Disability Index (ODI) success, back pain score, patient satisfaction, employment status, and reoperation. Odds ratios or mean differences and 95% credible intervals were reported., Results: Six studies were included (1417 participants). Overall, the activL total disc replacement device had the most favorable results for ODI success, back pain, and patient satisfaction. Results for employment status and reoperation were similar across therapies., Conclusion: activL substantially improves ODI success, back pain, and patient satisfaction compared with other therapies for single-level lumbar DDD.

Background: Advance care planning (ACP) empowers patients to consider and communicate their current and future treatment goals. However, it can be an emotionally charged process for patients with kidney disease and their caregivers. This study aimed to describe the perspectives and attitudes of patients with end-stage renal disease (ESRD) and their caregivers toward ACP., Study Design: Qualitative study., Setting & Participants: Patients with ESRD (n=24) and their caregivers (n=15) aged 36 to 91 years at various stages of ACP ("not commenced," "in progress," or "completed") from 3 renal services., Methodology: Semistructured interviews., Analytical Approach: Transcripts were analyzed using thematic analysis., Results: 5 major themes were identified: articulating core values (avoiding futile and undignified treatment, reevaluating terms of dialysis, framing a life worth living, and refusing to be a burden), confronting conversations (signifying death and defeat, accepting inevitable death, and alleviating existential tension), negotiating mutual understanding (broaching taboos and assisting conflicted caregivers), challenging patient autonomy (family pressures to continue dialysis, grief diminishing caregivers' capacity, and leveraging support), and decisional disempowerment (lacking medical transparency and disappointment with clinical disinterest)., Limitations: Only English-speaking patients/caregivers participated in the interview., Conclusions: ACP provides patients with ESRD and their caregivers a conduit for accepting and planning for impending death and to express treatment preferences based on self-dignity and value of living. However, ACP can be considered taboo, may require caregivers to overcome personal and decisional conflict, and may be complex if patients and caregivers are unable to accept the reality of the patient's illness. We suggest that ACP facilitators and clinicians make ACP more acceptable and less confrontational to patients and caregivers and that strategies be put in place to support caregivers who may be experiencing overwhelming grief or who have conflicting goals, particularly when they are called on to make end-of-life decisions., (Copyright © 2017 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Advance care planning (ACP) empowers patients to consider and communicate their current and future treatment goals. However, ACP is not widely implemented in chronic kidney disease (CKD) care settings. This study aims to describe clinicians' beliefs, challenges, and perspectives of ACP in patients with CKD., Study Design: Qualitative study., Setting & Participants: Nephrologists (n=20), nurses (n=7), and social workers (n=4) with a range of experience in facilitating ACP for patients with CKD across Australia., Methodology: Semistructured interviews were digitally recorded and transcribed verbatim., Analytical Approach: Transcripts were analyzed using thematic analysis., Results: 5 major themes were identified: facilitating informed decision making (avoiding preconceptions, conveying complete truths, focusing on supportive care, and synchronizing with evolving priorities), negotiating moral boundaries (contending with medical futility and respecting patient vs family autonomy), navigating vulnerable conversations (jeopardizing the therapeutic relationship, compromising professional confidence, emotionally invested, and enriching experiences), professional disempowerment (unsupportive culture, doubting logistical feasibility, and making uncertain judgments), and clarifying responsibilities (governing facilitation, managing tensions, and transforming multidisciplinary relationships)., Limitations: Some findings may be specific to the Australian context., Conclusions: The tensions among themes reflect that ACP is paradoxically rewarding for clinicians because ACP empowers patients yet can expose personal and professional vulnerabilities. Clinicians believe that a more collaborative approach is needed, with increased efforts to identify the evolving and individualized needs and goals of patients with CKD. Models of ACP that address clinicians' personal and professional vulnerabilities when initiating ACP may foster greater confidence and cultural acceptance of ACP in the CKD setting., (Copyright © 2017 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Conservative management of adults with stage 5 CKD (eGFR<15 ml/min per 1.73 m 2 ) is increasingly being provided in the primary care setting. We aimed to examine perceived barriers and facilitators for conservative management of older adults by primary care physicians., Design, Setting, Participants, & Measurements: In 2015, we conducted a cross-sectional, population-based survey of all primary care physicians in Alberta, Canada. Eligible participants had experience caring for adults ages ≥75 years old with stage 5 CKD not planning on initiating dialysis. Questionnaire items were on the basis of a qualitative descriptive study informed by the Behavior Change Wheel and tested for face and content validity. Physicians were contacted via postal mail and/or fax on the basis of a modified Dillman method., Results: Four hundred nine eligible primary care physicians completed the questionnaire (9.6% response rate). The majority of respondents were men (61.6%), were ages 40-60 years old (62.6%), and practiced in a large/medium population center (68.0%). The most common barrier to providing conservative care in the primary care setting was the inability to access support to maintain patients in the home setting (39.1% of respondents; 95% confidence interval, 34.6% to 43.6%). The second most common barrier was working with nonphysician providers with limited kidney-specific clinical expertise (32.3%; 95% confidence interval, 28.0% to 36.7%). Primary care physicians indicated that the two most common strategies that would enhance their ability to provide conservative management would be the ability to use the telephone to contact a nephrologist or clinical staff from the conservative care clinic (86.9%; 95% confidence interval, 83.7% to 90.0% and 85.6%; 95% confidence interval, 82.4% to 88.9%, respectively)., Conclusions: We identified important areas to inform clinical programs to reduce barriers and enhance facilitators to improve primary care physicians' provision of conservative kidney care. In particular, primary care physicians require additional resources for maintaining patients in their home and telephone access to nephrologists and conservative care specialists., (Copyright © 2016 by the American Society of Nephrology.)

Kidney supportive care describes multiple interventions for patients with advanced CKD that focus on improving the quality of life and addressing what matters most to patients. This includes shared decision making and aligning treatment plans with patient goals through advance care planning and providing relief from pain and other distressing symptoms. Kidney supportive care is an essential component of quality care throughout the illness trajectory. However, in the context of limited health care resources, evidence of its cost-effectiveness is required to support decisions regarding appropriate resource allocation. We review the literature and outline the evidence gaps and particular issues associated with measuring the costs, benefits, and cost-effectiveness of kidney supportive care. We find evidence that the dominant evaluative framework of a cost per quality-adjusted life year may not be suitable for evaluations in this context and that relevant outcomes may include broader measures of patient wellbeing, having care aligned with treatment preferences, and family satisfaction with the end of life care experience. To improve the evidence base for the cost-effectiveness of kidney supportive care, large prospective cohort studies are recommended to collect data on both resource use and health outcomes and should include patients who receive conservative kidney management without dialysis. Linkage to administrative datasets, such as Medicare, Hospital Episode Statistics, and the Pharmaceutical Benefits Scheme for prescribed medicines, can provide a detailed estimate of publicly funded resource use and reduce the burden of data collection for patients and families. Longitudinal collection of quality of life and functional status should be added to existing cohort or kidney registry studies. Interventions that improve health outcomes for people with advanced CKD, such as kidney supportive care, not only have the potential to improve quality of life, but also may reduce the high costs associated with unwanted hospitalization and intensive medical treatments., (Copyright © 2016 by the American Society of Nephrology.)

Unlabelled: ♦, Background: Patients are satisfied with their kidney care but want more support in making dialysis choices. Predialysis leaflets vary across services, with few being sufficient to enable patients' informed decision making. We describe the acceptability of a patient decision aid and feasibility of evaluating its effectiveness within usual predialysis practice. ♦, Methods: Prospective non-randomized comparison design, Usual Care or Usual Care Plus Yorkshire Dialysis Decision Aid Booklet (+YoDDA), in 6 referral centers (Yorkshire-Humber, UK) for patients with sustained deterioration of kidney function. Consenting (C) patients completed questionnaires after predialysis consultation (T1), and 6 weeks later (T2). Measures assessed YoDDA's utility to support patients' decisions and integration within usual care. ♦, Results: Usual Care (n = 105) and +YoDDA (n = 84) participant characteristics were similar: male (62%), white (94%), age (mean = 62.6; standard deviation [SD] 14.4), kidney disease severity (glomerular filtration rate [eGFR] mean = 14.7; SD 3.7); decisional conflict was < 25; choice-preference for home versus hospital dialysis approximately 50:50. Patients valued receiving YoDDA, reading it on their own (96%), and sharing it with family (72%). The +YoDDA participants had higher scores for understanding kidney disease, reasoning about options, feeling in control, sharing their decision with family. Study engagement varied by center (estimated range 14 - 49%; mean 45%); participants varied in completion of decision quality measures. ♦, Conclusions: Receiving YoDDA as part of predialysis education was valued and useful to patients with worsening kidney disease. Integrating YoDDA actively within predialysis programs will meet clinical guidelines and patient need to support dialysis decision making in the context of patients' lifestyle., (Copyright © 2016 International Society for Peritoneal Dialysis.)

Introduction: The number of elderly patients with advanced chronic kidney disease (ACKD) has increased in recent years, and the best therapeutic approach has not been determined due to a lack of evidence., Objectives: To observe the progression of elderly patients with ACKD (stages 4 and 5) and to compare the survival of stage 5 CKD patients with and without dialysis treatment., Material and Methods: All patients ≥70 years who began ACKD follow-up from 01/01/2007 to 31/12/2008 were included, and their progression was observed until 31/12/2013. Demographic data, the Charlson comorbidity index, history of ischaemic heart disease (IHD) and diabetes mellitus (DM) were assessed., Results: A total of 314 patients ≥70 years with stages 4 and 5 CKD were studied. Of these patients, 162 patients had stage 5 CKD at the beginning of follow-up or progressed to stage 5 during the study, and 69 of these patients were treated with dialysis. In the stage 5 group: median age was 77 years (74-81); 48% had IHD; 50% had DM, Charlson 7 (6-9). Kaplan-Meier survival analysis: ≥70 years (93 vs. 69 patients with dialysis, log rank: 15 P<.001); patients ≥75 years (74 vs. 46 patients with dialysis, log rank: 8.9 P=.003); patients ≥80 (40 vs. 15 patients with dialysis) and p=0,2. Patients receiving dialysis were younger, with a lower Charlson comorbidity index and shorter follow-up time., Conclusions: Our study shows that dialysis treatment improves survival, although this benefit is lost in patients ≥80 years., (Copyright © 2016 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.)

Lumbar spinal stenosis (LSS) is an increasingly prevalent condition that has major health and economic implications. While there are many options for the treatment of LSS, exercise is widely considered a first-line intervention as it is associated with reduced complications and cost as compared to more invasive options. Currently, it is not clear if exercise is an effective approach to managing pain and perceived disability in patients with symptomatic LSS. Therefore, the purpose of this systematic review is to evaluate the published literature that has investigated exercise as a primary intervention for LSS. A search was conducted in electronic databases including PubMed, PEDro, SPORTDiscus, CINAHL, and AMED using the key words lumbar spinal stenosis, exercise, physical therapy, rehabilitation, and conservative treatment. Inclusion criteria consisted of published randomized controlled trials written in English that included exercise as the primary treatment in at least one of the groups, and had reported measures of pain and disability clearly stated. The search identified 310 studies of which 5 met all the inclusion parameters. Exercise appears to be an efficacious intervention for pain, disability, analgesic intake, depression, anger, and mood disturbance among patients with LSS. Further research is needed to determine which type of exercise is the most effective in managing symptoms associated with lumbar spinal stenosis.

Background and Objectives: Conservative kidney management (CKM) has been developed in the United Kingdom (UK) as an alternative to dialysis for older patients with stage 5 CKD (CKD5) and multiple comorbidities. This national survey sought to describe the current scale and pattern of delivery of conservative care in UK renal units and identify their priorities for its future development., Design, Setting, Participants, & Measurements: A survey on practice patterns of CKM for patients age 75 and older with CKD5 was sent to clinical directors of all 71 adult renal units in the UK in March 2013., Results: Sixty-seven units (94%) responded. All but one unit reported providing CKM for some patients. Terminology varied, although "conservative management" was the most frequently used term (46%). Lack of an agreed-upon definition of when a patient is receiving CKM made it difficult to obtain meaningful data on the numbers of such patients. Fifty-two percent provided the number of CKM patients age ≥ 75 years in 2012; the median was 45 per unit (interquartile range [IQR], 20-83). The median number of symptomatic CKM patients who would otherwise have started dialysis was eight (IQR, 4.5-22). CKM practice patterns varied: 35% had a written guideline, 23% had dedicated CKM clinics, 45% had dedicated staff, and 50% provided staff training on CKM. Most units (88%) provided primary care clinicians with information/advice regarding CKM. Eighty percent identified a need for better evidence comparing outcomes on CKM versus dialysis, and 65% considered it appropriate to enter patients into a randomized trial., Conclusions: CKM is provided in almost all UK renal units, but scale and organization vary widely. Lack of common terminology and definitions hinders the development and assessment of CKM. Many survey respondents expressed support for further research comparing outcomes with conservative care versus dialysis., (Copyright © 2015 by the American Society of Nephrology.)

Background: Although dialysis prolongs life for patients with end-stage kidney disease, 20% of deaths in this population are preceded by dialysis therapy withdrawal. Recently, there has been more focus on conservative (nondialytic) care as a legitimate option, particularly for elderly patients. This study aims to describe patients' and caregivers' perspectives on conservative treatment and end-of-life care in chronic kidney disease (CKD)., Study Design: Systematic review and thematic synthesis of qualitative studies., Setting & Population: Patients with CKD and caregivers., Search Strategy & Sources: MEDLINE, Embase, PsycINFO, CINAHL, and reference lists were searched to May 2013., Analytical Approach: Thematic synthesis was used to analyze the findings., Results: 26 studies involving more than 711 patients (non-dialysis dependent [n=41], hemodialysis [n=544], peritoneal dialysis [n=9]; unspecified dialysis modality [n=31], conservative management [n=86]) and 178 caregivers were included. We identified 5 themes: invasive suffering (bodily deterioration, loss of freedom and independence, unyielding fatigue and pain, resignation, treatment burden and harm, financial strain), personal vulnerability (imminence of death, misunderstanding and judgment, autonomy and dignity, medical abandonment, trust and safety), relational responsibility (being a burden, demonstrating loyalty, protecting others from grief), negotiating existential tensions (accepting natural course of life, disrupted aging, worthlessness, living on borrowed time, respecting sanctity of life, life satisfaction, preserving self-identity), and preparedness (decisional clarity, informational power, spirituality and hope)., Limitations: Non-English articles were excluded; therefore, the transferability of findings to other populations is unclear., Conclusions: Some patients with CKD experience physical and psychosocial frailty and feel ambivalent about prolonging life. Some caregivers believe in providing relief from suffering, but are uncertain about making decisions regarding dialysis therapy initiation and discontinuation. We suggest that CKD management should encompass palliative care strategies that promote emotional resilience, sense of well-being, and self-value. Also, respectful and attentive communication may empower patients to convey their values and preferences about their own care., (Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)