General introduction 13 1 b) Patient barriers to CPR decision-making and implementation (17): ● lack of understanding of CPR and its success rate; although this misunderstanding concerned physicians, they contributed to it as the information provided can vary across disciplines and contains a lot of medical jargon c) Physician barriers to end-of-life care and ACP: ● difficult timing: poor recognition of a proper starting moment for ACP (18), the unpredictability of the prognosis and uncertain transitions toward the end of life (18–20), perceived inappropriateness of the current setting (e.g. inpatient or intensive care) to discuss ACP (18) ● unreadiness on the physicians’ side: not ready to give up an aggressive approach (21,22), reluctance to discuss ACP when not all treatment options are exhausted (20,22), feeling obligated to improve patient’s well-being (21), discomfort (20), avoidance of talking about end-of-life all together (21) ● patient factors: concern ACP conversations lead to anxiety, depression and take away patients’ hope (18,21,22), avoidance to confront the patient with the end-of-life (19), denial on the patients side (19), the (false) beliefs that the patient is not ready to talk about the end of life (21,22), the patient does not know what (s)he wants (21), or the patient does not want treatment limitations (18) ● inadequate training and (communicational) knowledge and education (18–20) ● time constraints (18,20,21) d) Patient barriers to end-of-life care and ACP: ● the assumption that the physician will initiate the discussion when necessary (18,20,22) ● perceived irrelevance (22–27) ○ even in a study in cancer patients with a life expectancy < 12 months, it was experienced as being too early (28) ● lack of education (18,22,27,29), poor medical literacy (18,23) ● emotions: fear of abandonment (18,23), anxiety (20), denial (20,21) ● uncertainty about what choices to make and variability of these choices (21,22) ● the perception the physician does not like to talk about it (21,22) or is too busy (23)
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