Individuals 70 and older are the fastest growing group of patients with end-stage renal disease (ESRD). Research shows that decision-making regarding initiation of dialysis is impaired by poor communication and lack of understanding about the options for management of ESRD. Some small studies suggest that, among older adults, dialysis is likely associated with longer life expectancy compared to conservative management without dialysis. Yet little is known about what older adults can expect after initiating dialysis in terms of patient- centered outcomes such as functional status and cognitive function. Furthermore, there has been little research into patient, family, and clinician perspectives on this decision-making process. This proposal has the following three complementary aims that address these challenges related to dialysis decision-making: 1) Define the trajectories of functional status and cognitive function for adults 70 and older with ESRD before and after initiation of dialysis, compared to the trajectories of adults not on dialysis. 2) Explore perspectives about the decision to initiate dialysis (versus conservative management) among adults 70 and older, their families, and clinicians. 3) Develop a decision aid for older patients with impending ESRD. The first project is a quantitative analysis using nationally-representative longitudinal survey data from the Health and Retirement Study. The second project features qualitative interviews with patients, families, and clinicians about the dialysis decision-making process. The third project will use the knowledge gained from Aims 1 and 2 to inform the design of a decision aid for adults 70 and older who are expected to need dialysis. The overall objective of this K23 Career Development Award (CDA) is to support the early career of Dr. Melissa Wachterman, a palliative care physician and health services researcher at Harvard Medical School. Dr. Wachterman is a promising junior investigator specializing in research related to geriatric palliative care. Her career goal is to become an independently-funded clinician-investigator conducting research that improves quality of care and patient-centered treatment decision-making for seriously-ill older adults and their families. This K23 award will help Dr. Wachterman accomplish the following goals: 1) to obtain advanced training in biostatistics, including analytic skills using longitudinal nationally-representative survey data; 2) to acquire training in qualitative research methods; 3) to develop skills in decision aid development; 4) to develop as an investigator to ensure a successful transition from this CDA to independent R01-level funding. To achieve these goals, Dr. Wachterman has a mentoring team committed to her success as a clinician investigator. Her primary mentor is Dr. Nancy Keating, Associate Professor of Medicine and Health Policy at Harvard Medical School and an internationally-recognized health services researcher with exp...