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212 Chapter 11 beyond specific strengths and limitations that have been discussed in previous chapters. Third, considerations about DA implementation will be discussed. This general discussion ends with implications for clinical practice and for future research, before a general conclusion is presented. Considerations about DA development The decision to develop an online-only DA was based on the high degree of internet access among the entire Dutch population (>97%) 3 , and the wider possibilities to tailor information provision and present values clarification methods. We modified a pre-existing, evidence-based tool that was developed in Canada 4 .Patients differ in their information needs, capabilities to process information, and their desired level of involvement into a medical (treatment) decision 5-7 . Yet, DAs aimed to support patient decision-making and initiation of SDM, have been developed according to a single one-size-fits-all format. Also the DA evaluated in this dissertation was developed to be universally applicable to all Pca patients. Perhaps it was for this reason that we learnt that 20% of participating patients would have preferred a paper format over the online format.This evaluationwas actuallyprovidedbypatientswhoconsented tocomplete the questionnaires which were also online by default (paper on request). It could therefore be possible that these 20% of participants are actually an underrepresentation of the total population of Pca patients who would prefer to use a paper DA over an online DA. Although it was determined prior to DA development that almost all citizens in the Netherlands have internet access at home, it is possible that for a serious – potentially life threatening – disease, and the associated process of selecting treatment, many patients prefer an offline environment for information and decision support. Compared to online tools, which are often intended to be used outside consultations, an important advantage of offline tools is that they can be incorporated more easily in clinical consultations. Based on the results of the studies in this thesis, it can be suggested that patients who are lower educated and report anxious or depressive symptoms, could benefit from more counseling or integration of the DA into the actual clinical consultation. More variation in DA format and delivery methods in order to personalize to patients needs is therefore important. As seen within the JIPPA study, with the offline and more concise DAs, an even larger proportion of patients was satisfied with the format (chapter 10). Compared to the other two JIPPA DAs evaluated in chapter 10, the current DA was the most extensive, and also the only to include explicit values clarification exercises (VCEs) (chapter 3). Such exercises help patients in the process of clarifying personal values that are relevant to the decision, and are therefore a widely recommended element in DAs 1,4,