Chapter 1 12 Relevance Certainly, it did not occur unexpectedly that discussing care decisions became one of the ten “Wise Choices” ” (10). Early and proactive conversations regarding care decisions enables the provision of care that is more closely aligned with patient preferences and is associated with reduced consumption of healthcare resources (13). Care decision conversations are crucial to ensure future healthcare decisions are aligned to a patient’s wishes and have shown to reduce length of stay in the intensive care unit (ICU), ICU readmission rates and costs of healthcare, without impacting patient satisfaction (14–16). This raises the question of why these conversations are not conducted more frequently or in a timely manner. Barriers among physicians and patients Presumably care decision conversations are not conducted in a timely manner, because both physicians and patients avoid them due to numerous barriers. In literature, barriers to cardiopulmonary resuscitation (CPR) orders, end-of-life care and ACP in several (end-of-life) settings are identified. It is reasonable to anticipate that these barriers, though with certain subtleties, may also apply to care decision conversations. To have a good overview below are summaries of a) physician barriers to CPR decision-making and implementation, b) patient barriers to CPR decision-making and implementation, c) Physician barriers to end-of-life care and ACP, d) patient barriers to end-of-life care and ACP, and e) system barriers to end-of-life care and ACP. a) Physician barriers to CPR decision-making and implementation (17): ● training and confidence: feeling unskilled or inadequately trained, exhibiting low confidence, inexperience, discomfort, embarrassment, difficulty in making decisions themselves, avoidance of the responsibility of decision-making ● patient factors: poor health status, fear to cause anxiety or distress, fear of harming the patient, fear of complaints and experiences with verbally or physically aggressive relatives, medical uncertainty and perceived resistance from the patient, as physicians often underestimate the number of patients willing to discuss their CPR status
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