Best Case/Worst Case: A Multisite Randomized Trial of Scenario Planning for Patients With Late-Stage Kidney Disease

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• Picked for Nephrology (top studies of the week, 6 September 2026): Cluster RCT, communication tool for dialysis decisions

Abstract

BACKGROUND: Best Case/Worst Case (BC/WC) is a communication tool to support nephrologists and older adults with advanced chronic kidney disease with decisions about dialysis. We compared the effectiveness of training nephrologists to use BC/WC versus usual care on receipt of palliative care, quality of life (QOL), quality of communication, dialysis initiation, and death. PARTICIPANTS AND SETTING: From February 2021 to December 2023, we enrolled patients at 10 US sites who were ≥ 60 years, had an estimated glomerular filtration rate (eGFR) ≤ 24 mL/min/1.73m2, with estimated survival ≤ 18 months, and were considering dialysis initiation in the outpatient setting. We randomized nephrologists to intervention or usual care. METHODS: In this cluster randomized trial, we followed patients for up to 2 years using chart review and patient and caregiver surveys. The primary outcome was receipt of palliative care within 12 months of patient enrollment. RESULTS: We enrolled 68 nephrologists (36 intervention) and 268 patients (105 intervention). On intention-to-treat analysis, receipt of palliative care within 12 months did not significantly differ between groups (hazard ratio (HR) 0.94, 95% Confidence Interval (CI), 0.59-1.52; p = 0.812). Patients of intervention nephrologists were more likely to initiate dialysis (HR, 1.50, 95% CI, 1.00-2.25; p = 0.048) and report worse QOL throughout the study (FACIT-Pal effect estimate, -6.51; 95% CI, -12.20, -0.81; p = 0.025; FACT-G effect estimate, -4.78; 95% CI, -8.35, -1.22; p = 0.010). We found no significant differences in intensity of treatment at the end of life, quality of communication, or on-study death between groups. CONCLUSION: Training nephrologists to use the BC/WC communication tool does not significantly affect receipt of palliative care or other measurable clinical outcomes. TRIAL REGISTRATION: NCT04466865 (URL: clinicaltrials.gov/study/NCT04466865), registered 07/07/2020.

Abstract as published, via PubMed.