15250-m-cuypers

213 Summary and general discussion 11 8 . However, a clear definition of VCEs is not available, resulting in a broad variety of tasks that can be seen as values clarification, with most common exercises at least including the rating, ranking or discussion of pros and cons 8 . When patients engage in such exercises, this helps the cognitive processing of all options, offers time to process new information and to retrieve memories relevant to the decision. Furthermore, it allows comparing options and stimulates reviewing treatment-specific aspects or personal values that might not have been considered otherwise 9 . Inclusion of VCEs can be seen as an effort to stimulate deliberation about the presented treatment aspects. Whereas in many real-life situations, and for medical decisions specifically, the general assumption often is that deliberative analysis is the best strategy to make a decision, this may not always be the case 10, 11 . Earlier scenario-based studies suggested that this may result in people choosing treatment that has more risks than the disease itself or avoiding treatment with possible adverse effects, while the mortality risk of the disease is higher 12,13 . Stimulating deliberationmight result in people feeling better about their decision, as they put more effort in reaching a decision, while the decision itself might be the same and possibly still not provide an optimal patient- treatment fit 14 15 . This could have been reflected in the knowledge scores reported in chapter 6; while DA users felt more knowledgeable, their knowledge test scores were similar to the scores of participants from the control arm. The VCEs within the current DA presented two unique treatment option attributes as a trade-off to elicit a preference towards one of the two presented treatments (e.g. the fear of postponing active treatment with AS versus undergoing possibly unnecessary active treatment with the risk for adverse effects; chapter 4). Although trade-offs have been recommended to reach value-congruent decisions 16 , the tasks were developed without specific (evidence-based) development guidelines 16, 17 . The following two suggestions for further refinement and improvement of the DA in later DA versions may be considered. First, the VCE trade-offs in the current DA were presented with their corresponding treatment, however, identifying the associated treatment can influence preferences 18 . For a patient, the tendency to be consistent with a pre-existing (biased) preference could then be confused with the true treatment preference. Second, one in three DA users preferred a treatment advice as outcome after DA use, possibly caused by the expectation of receiving an output after providing input by answering the VCEs. Providing an advice would also have to include weighing of attributes, since one particular treatment aspect (e.g. avoiding adverse treatment effects) could outweigh all other presented treatment aspects. Including best-worse scaling of the current trade- offs could be considered 19 .