Table 2 GP participant quotes pertaining to four identified themes
Theme One Age-related change in kidney function | |
|---|---|
Increased prevalence | “I’m much more cautious in older people, because you would expect them to have kidney problems by the fact that they are getting older.” [GP8] |
“Usually for patients more than 70 years old, we pretty much see as renal impairment, no matter how good their weight, their blood pressure and everything else is. So I just say that this is normal.” [GP61] | |
Physiological change | “Well a lot of older patients do have a deterioration of renal function anyway that could be just due to age-related changes in the blood supply.” [GP2] |
Diagnosis | “I’d say, … the medical term is CKD which means chronic kidney disease … it’s what it’s called but the way I like to think of it … is that your kidneys aren’t working as well.” [GP36] |
Guidelines non-specific | “I’m sure many GPs are concerned that there are so many tests and so much management, at what point do you continue this with someone who’s quite elderly, are we over testing or are we under testing?” [GP1] |
Risk management | “Well yes it does I guess, simply because everybody’s eGFR goes down with age, … but I think that we don’t underestimate the importance of still managing that risk as well as you possibly can.” [GP50] |
“I guess because they are older and because my thinking is that something else may intervene and then sometimes when we get too active in our interventions, we start throwing lots of tablets and medications and things at people and that impacts on them, makes them more unwell really or not feel any better. So I’m probably more looking at quality of life, rather than just longevity, if you like.” [GP25] | |
“I guess I have a higher tolerance for a lower GFR in those groups, it’s almost expected. But we can’t be complacent about it either, I understand it; it can be a sign of propensity to further significant kidney disease.” [GP27] | |
Theme Two Whole Person Care | |
Whole person | “It’s not that the body is apart, but its combined.” [GP8] |
“I don’t focus on the kidneys per se. I focus on the entire health.” [GP51] | |
Overlapping guidelines | “I probably don’t specifically think about kidney disease is what I’m testing, I’d probably do it more in terms of cardiovascular disease.” [GP25] |
“Happily a lot of the management you do for a number of chronic conditions coincides nicely with the same for CKD.” [GP27] | |
“There are so many guidelines.” [GP5] | |
Balancing risks and harms | “In the elderly you’ve got to be a little bit careful with overtreating (blood pressure)” [GP1] |
“Accepting that you may need to be a little bit circumspect, depending on if there are other comorbidities or frailties with the patient.” [GP2] | |
Medication management | “If they don’t have a life limiting illness and you’re just managing a lot of things, mental health, pain, decreased renal function, obviously I want to look after their kidneys so it’s always a factor in what I’m prescribing” [GP51] |
“I have a few older patients who are probably a little annoyed at me because I take them off their anti-inflammatories because I think it’s more important, but then they complain that their osteoarthritis has flared back up again.” [GP66] | |
“I generally don’t find it too much of an issue to be honest. Most of the time you can easily juggle around…. multiple medications. You can easily juggle around or find alternatives.” [GP75] | |
“Most of the time is monitoring. At other times is trimming out medications or even increasing some medications, depending.” [GP16] | |
Theme Three Patient-centred care | |
Shared-decision making | “The first thing is what is the patient’s wishes, is it quality of life or do they want to live for as long as possible?” [GP51] |
“There’s a point where, you know, I suppose the life expectancy and the risk of life, you’re going on a preventative aim with your treatment and there’s a point where then you’re looking at trying not to cause harm and then there’s a point where you’re probably just trying to provide palliative care and quality of life. I suppose that is different for everyone, I think and it’s somewhat a decision between patients and doctors.” [GP57] | |
“Often very elderly people aren’t that interested in heroic interventions and I have a chat with them about quality versus quantity of life and try and work out what is important with them and then go ahead accordingly with interventions or monitoring… I’m guided by them very much.” [GP27] | |
Lifestyle change | “You can’t change the mind of anyone in that age. They’ve got the good habits or they don’t, you know, no one suddenly becomes a gym junkie in their 70s.” [GP51] |
“We have got remarkable older patients, its just a matter of getting a shared goal, and I’ll often do- we have got amazing patients, I must say, who are really quite inspirational.” [GP50] | |
“There are a fair few patients that I can think of whose social and yes, mental health and emotional issues far outweigh any physical issues they have for them.” [GP36] | |
Quality of life | “It probably comes down to looking at their general quality of life… I think it’s just probably encouraging them to live as well as they can.” [GP50] |
“I do lean on patient quality of life.” [GP69] | |
“You look at their symptoms rather than their disease stats.” [GP2] | |
Theme 4 Process of care | |
Opportunistic vs. routine | “If they come in for something else I take the opportunity.” [GP30] |
“I think you’re probably more likely to already have an eGFR on record.” [GP1] | |
“We have a pretty formalised process…. Everyone gets a free shirt when they have an annual health check, so people come in for their shirt.” [GP10] | |
Burden of care | “Normally when you are busy and firefighting you don’t think about renal function” [GP8] |
“I think, as part of a general health review that we might do a little bit more often in older people, because we see them more often. We have the over-75 health assessment, which is another moment of time with patients. So I think it’s almost a more systematic approach and we’ve just got a - so I just do it as part of a list of a whole lot of other things.” [GP22] | |
Referrals | “It would worry me that if we referred everybody off in the categories where you need to refer off in elderly patients, it would swamp clinics that perhaps then means people who really need to be seen quickly by a nephrologist.” [GP1] |