When Shared Decision-Making Meets Organisational Reality: How Nephrologists Navigate Dialysis Modality Selection—A Q Method Study

When a person's kidneys fail completely, the body can no longer filter waste and excess fluid from the blood. Without intervention, this condition is fatal. For decades, the standard solution has been in-center hemodialysis, where patients travel to a clinic several times a week to sit connected to a large machine that performs the filtering work. However, there are other ways to manage this life-threatening condition. Some patients can perform dialysis at home, either by using a machine during the night or by infusing a special fluid into their abdomen to clean the blood. These home-based options often offer greater freedom and can lead to better quality of life for many. Yet, despite their benefits, most patients worldwide still end up in the clinic. The reasons for this are rarely about the patients themselves or the medical outcomes, but rather about the invisible culture of the hospitals and the habits of the doctors who guide them.

A team of researchers in Belgium set out to understand why this gap exists. They focused on a concept called shared decision-making, which is the ideal process where a doctor and a patient sit down as partners to choose the best treatment path. In theory, the doctor explains the options, and the patient chooses what fits their life. But in the real world, doctors are human beings with their own beliefs, fears, and pressures. The researchers wanted to see how kidney specialists actually think about this process. Do they truly share the power of choice with the patient, or do they subtly steer the conversation toward the clinic, even when they claim to be open to home care? To find out, they did not just ask doctors what they believed; they asked them to sort through a series of statements about how decisions should be made, forcing them to reveal their deepest priorities and contradictions.

The study involved twenty-five kidney specialists from across Belgium, representing a mix of ages, experience levels, and hospital settings. The researchers gave each doctor a scenario about a sixty-year-old patient approaching the need for dialysis. The doctors were then asked to rank nine different statements that described various ways a doctor might handle the decision. Some statements emphasized total patient freedom, others focused on the doctor's duty to protect the patient, and some highlighted the role of nurses or family members. As the doctors sorted these statements, they spoke their thoughts aloud, explaining why they placed certain ideas at the top and others at the bottom. This method allowed the researchers to see not just what the doctors said they would do, but how their minds actually worked when faced with a difficult choice.

The analysis revealed that the doctors did not all think alike. Instead, they fell into three distinct groups, each with a different way of viewing the relationship between doctor and patient. The largest group, representing about one-third of the participants, saw themselves as part of a team. They believed in supporting the patient's choice, but only if that choice was safe and could actually work within the limits of their hospital and the healthcare system. For these doctors, the patient's freedom was real, but it had to be balanced against the reality of staffing, logistics, and the need to keep the whole system running smoothly. They felt it was their job to gently guide patients away from choices that might fail, viewing this guidance not as control, but as a necessary safety net.

A second group, which was smaller, held a much more rigid view of who should be in charge. This group was split between two extremes. On one side were doctors who believed the patient should have absolute power to choose anything, regardless of the consequences for the medical team or the patient's own health. On the other side were doctors who believed the physician should be the one to make the final call, prioritizing the organization's schedule and the doctor's expertise over the patient's wishes. Surprisingly, both sides of this group agreed on one thing: the decision should rest with a single person, either the patient or the doctor, rather than being a true collaboration. They did not see the value in a messy, shared process where everyone has a say.

The third group, making up about a quarter of the doctors, focused heavily on education and support. They believed that the key to a good decision was not just the doctor's advice, but the influence of nurses and other patients who had already been through the experience. For them, the doctor's role was to step back and let nurses and peer mentors help the patient understand what home dialysis really meant. They trusted that if patients could talk to others who were doing it successfully, they would make the right choice. This group saw the decision as a collaborative effort involving the patient, the doctor, and the nursing team, with the goal of empowering the patient through knowledge and shared experience.

While all three groups claimed to reject the idea of a doctor forcing a decision on a patient, the deeper interviews told a more complicated story. When the researchers asked the doctors to talk through real-life examples, many admitted that they often restricted the options presented to patients before the conversation even began. They might decide early on that a patient was too frail, too messy, or too socially vulnerable to handle home care, and therefore never offer it as a real possibility. They often justified this by saying they were protecting the patient or the system, but the researchers noted that these doctors rarely recognized this behavior as a form of control. Instead, they saw it as common sense or a necessary rule of the hospital.

The study found that these restrictions often happened because of the environment the doctors worked in. If a hospital did not have enough nurses trained to teach home dialysis, or if the administration did not want to spend money on a home program, the doctors felt they had no choice but to steer patients toward the clinic. They described a situation where the system itself made home care seem impossible, even if the patient wanted it. Some doctors admitted that they would only support a home therapy if they were confident it would work perfectly, and if there was any risk of failure, they would pull the plug quickly. This created a cycle where patients were rarely given a fair chance to try home care, and when they did, they often failed because they lacked the full support system they needed.

The researchers concluded that the problem is not just about individual doctors being stubborn or paternalistic. It is about a culture where the default option is the clinic, and home care is treated as an exception that requires too much effort to justify. Even doctors who wanted to offer home care often felt trapped by the rules of their workplace and the lack of training for their staff. They tended to solve problems one case at a time, trying to fix barriers as they appeared, rather than trying to change the system itself. The study suggests that until the healthcare system changes to support home care as a standard option, rather than a special project, doctors will continue to limit the choices they offer patients, often without realizing they are doing so. The gap between what doctors say they believe and what they actually do remains wide, shaped by the invisible walls of organizational reality.