Advanced Chronic Kidney Disease: Planning for Dialysis
Your Role — Doctor
Renal Clinic
Your 58-year-old patient has chronic kidney disease that has progressed to stage 4, with kidney function continuing to decline. It is time to start planning for future renal replacement therapy (dialysis or transplant) before it becomes urgent. The patient is frightened by the word dialysis and reluctant to think about it while they still feel relatively well. You need to explain the situation and options and begin advance planning sensitively.
- •Explain in plain terms how the kidney function has changed and what stage 4 means, checking existing understanding.
- •Explain why it's important to plan ahead now, while the patient feels well, rather than waiting for a crisis.
- •Introduce the main options (haemodialysis, peritoneal dialysis, transplant, and conservative care) at an overview level without overwhelming.
- •Explore and address the patient's fears about dialysis and their reluctance to plan while feeling well.
- •Agree the next steps (education session, access planning, specialist nurse, follow-up) and reassure that decisions are shared and not being rushed.
The Interlocutor
Played by the actor / assessor
You are 58 with kidney disease you've known about for years. You feel reasonably well and are shocked to hear the word dialysis, which you associate with being permanently tied to a machine and the end of normal life. You'd rather not think about it while you still feel okay.
- •Say you feel fine, so you don't understand why you need to talk about dialysis now.
- •React with fear to the word dialysis — you picture being stuck to a machine for the rest of your life.
- •Ask whether this means your kidneys are about to fail completely.
- •Ask whether there are any options other than dialysis, or whether a transplant is possible.
- •If the doctor is reassuring and explains that planning ahead protects your options, agree to attend an education session and think it over.
Sample Role-play
Hello Mr Bianchi, I'm Dr Hassan. Thank you for coming in. I'd like to talk about your recent kidney results and about planning ahead. How have you been feeling in yourself?
Honestly, I feel pretty well. So I'm not sure why we need a big conversation.
I'm really glad you feel well, and that's actually the best time to have this conversation. Your latest tests show your kidney function has dropped to what we call stage 4 — the kidneys are working at a reduced level and slowly declining. You're not in trouble today, but planning now, while you're well, gives you the most choice later.
Stage 4… does that mean my kidneys are about to pack up completely?
Not imminently — it's a gradual process, and we can't put an exact date on it. But at some point the kidneys may not do enough on their own, and that's when treatments to replace their work come in. Talking about it early means we're never caught out in an emergency.
You mean dialysis. That word terrifies me — being hooked to a machine for the rest of my life.
I completely understand that fear — it's a big word and it carries a lot of frightening images. Let me reassure you that dialysis today is more flexible than many people picture, and it's not the only path. Would it help if I gave you a brief overview of the options, without any pressure to decide anything today?
Alright, as long as I don't have to choose right now.
Absolutely not — no decisions today. Broadly there are a few routes: one type of dialysis done at a unit a few times a week, another type you can do at home, the possibility of a kidney transplant, and for some people a approach focused on comfort without dialysis. Each has pros and cons, and we'd match it to your life and wishes.
A transplant — could I have that instead of dialysis?
For some people, yes, and it can be explored — sometimes even before dialysis is needed. There's an assessment process and it depends on your overall health and finding a suitable kidney, but it's a real option we can look into. I don't want to over-promise, but it's absolutely worth exploring.
That's more hopeful than I expected. So what happens now?
The next step is a relaxed education session with our specialist nurse, where you and your family can ask everything and see what each option really involves. We'll keep monitoring your kidneys, and if we do head towards dialysis, we plan the access well in advance so nothing is rushed. I'll write this down and you'll have a nurse to contact any time.
Okay. I can do that. Thank you — I was dreading this conversation.
You've approached it really thoughtfully, and remember nothing is being decided without you. Take your time, bring your questions, and we'll go through each step together.
Useful Phrases
Clinical Background
CKD stage 4 (eGFR 15–29) warrants advance planning for renal replacement therapy before reaching stage 5. Options: haemodialysis (in-centre or home), peritoneal dialysis, pre-emptive or later transplantation, and conservative/supportive management for those who choose not to dialyse. Early access planning (AV fistula, PD catheter) avoids emergency dialysis via lines. Multidisciplinary education supports informed, shared decisions. Address the strong emotional associations of 'dialysis' and preserve the patient's sense of choice and control.
Common Mistakes to Avoid
- ✕Pushing dialysis planning without acknowledging why a well-feeling patient is reluctant to engage.
- ✕Overwhelming the patient with detailed comparisons of every modality in one sitting.
- ✕Failing to mention transplantation and conservative care as legitimate options alongside dialysis.