ABSTRACT
Background: Older adults faced treatment decisions for kidney failure during the COVID-pandemic, despite high risk of hospitalization, intensive care, and death. Given heightened uncertainty, clinicians needed to adapt communication about risks, benefits, and treatment decisions during the COVID-19 pandemic. Understanding how to support decision-making during uncertain times can guide clinicians in future public health crises. Methods: Qualitative study using semi-structured interviews (August-December 2020) with CKD stage 4-5 patients, age 70+, carepartners, and clinicians in Boston, Portland, Maine, San Diego, and Chicago. Thematic analyses were conducted. Results: Among 76 participants (39 patients, 17 carepartners, 20 clinicians) 13 patients (33%) identified as Black, and 7 (18%) were receiving dialysis. Four themes characterized treatment decision-making during the COVID-19 pandemic: Difficulty communicatng risk: balancing hope with caution;Clinicians' increased support for home dialysis;Patient confidence in chosen modality;and Coping with uncertainty and isolation in CKD. Clinicians struggled to balance discussion of COVID-19 risks while preserving hope. Black patients reported fewer conversations about COVID-19 risks than White patients and had more unaddressed questions. Clinicians reported being more open to home dialysis than pre-COVID-19. While some patients expressed interested in conservative management, few clinicians offered conservative management as an option. All patients who had initiated treatment prior to COVID-19, irrespective of modality, believed that their treatment was safest and optimal during the pandemic. With few clinical converations incorporating COVID-19-specific risks, patients and carepartners struggled to cope, finding both in-person and telehealth visits safe but isolating. Conclusions: Although clinicians struggled communicating about COVID-19 leaving patients with unadressed concerns, patients across modalities felt safe and confident in their treatment. Clinicians developed an openness to home dialysis, though few offered conservative management despite patient preferences. Research should examine optimal approaches to enhance communication and shared-decision making to prepare for future systemic challenges.