Chapter 1 14 e) System barriers to end-of-life care and ACP: ● life-sustaining care is the default, no (support) systems for end-of-life care (20) ● poor systems for recording patient wishes (20) ● ambiguity about who is responsible (20) As stated before, probably these barriers, though with certain subtleties, also apply to care decision conversations. The avoidance by both parties often leads to the absence of these crucial conversations. To surmount these barriers and make way for fruitful conversations regarding care decisions, both physicians and patients need tailored support. Setting The quality standards of the Dutch association for Internal Medicine demand that a code status is documented in every admitted patient (30). In a code status, it can be documented whether there are limitations to specific life-sustaining treatments or not. When both physicians and patients avoid talking about care decisions (because of the earlier mentioned barriers), these conversations do not take place in time (31). Consequently, the opportunity to adapt treatment to align with patient’s wishes is often missed (32). As a result, care decision conversations often take place at the Emergency Department (ED) in order to document a code status. This seems a far from ideal situation, because at the ED there is limited time and sometimes an acutely ill patient (33,34). Furthermore, in such circumstances, code status (and primarily CPR status) is discussed merely to ‘tick a box’, fulfill a requirement on the admission note and sign out, without giving due consideration to the patient’s goals and values (35). On top of that, in acute settings preexisting physician-patient relationships are rare and there is minimal time to develop familiarity with the patient, their illness and their goals of care (34). Initiating timely conversations regarding care decision can lead to care that is more closely aligned with patient preferences and reduced consumption of healthcare resources (13). The outpatient clinic, often a setting where patients consult a physician with whom they are familiar, appears to be a more appropriate setting to such conversations (36–39). However, the care decisions conversation in the outpatient clinic is often perceived as being too soon by both the patient and the physician (32,34,40). Consequently, these
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