Chapter 6 120 1. Introduction Care decisions comprise a broad spectrum of topics, all with the purpose to align treatment with the preferences of the patient. This includes code status documentation (i.e. whether limitations to specific life-sustaining treatments are in place) and all forms of advance care planning. In 2014, the Dutch association for Internal Medicine compiled a list of ten Wise Choices to improve the quality and efficiency of healthcare in the spirit of the nationwide Choosing Wisely Campaign.1–5 One of these is to discuss care decisions when discussing treatment with patients.2 Although this implies care decision discussions should be a regular part of the medical consultation, both physicians and patients face multiple barriers in doing so, leading to avoidance of the topic. 6–12 Besides, the care decisions discussion in the outpatient clinic is often perceived as being too soon.9–11 This results in postponing care decision discussions until the end of life, which is reflected in research conducted mostly in these endof-life settings.12 Over the past decades, patient centered care and shared decision making has become the ideal model for doctor-patient decision making.13–15 Within the framework of patient centered care, physicians are encouraged to partner with patients to co-design and deliver personalized care.16 It is surprising that despite the well-acknowledged importance of patient centered care and shared decision-making, both physicians and patients tend to avoid conversations about care decisions, a topic in which patient centered care and shared decision making are particularly important. The quality standards of the Dutch association for Internal Medicine demand a code status is documented in every admitted patient.17 In a code status, it can be documented whether there are limitations to specific life-sustaining treatments or not. As a result from the avoidance and postponement of care decision discussions earlier in life, care decision discussions often take place at the ED to document a code status. This documentation, or registration, is only a small part of what we attempt to accomplish with improving care decision discussions. In a previous study, we saw the registration of a code status in hospitalized patients in our hospital is quite good (70%-73%).18 However, we are unaware of the quality of care decision discussions at the emergency department.
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