Chapter 7 148 number of care decision conversations we observed (21/150, 14%)(chapter 3) is even lower than the number of patient reported care decision conversations (45/161, 28%)(chapter 2). This discrepancy cannot be explained by the number of failed video-recordings. A possible explanation might be that care decisions are discussed in another visit, despite the instruction given to patients that the questionnaire was about the last video-recorded visit. Conversation analysis of these real care decision conversations at the outpatient clinic, showed us how hard it was to introduce the topic of care decisions. Hesitation markers, repairs and hypothetical talk characterized the care decisions conversation, showing the precariousness of the topic. Furthermore, there is no destined phase or interactional slot for the introduction of the topic of care decisions. In addition, common ground needs to be created and relevance needs to be accounted for. Physicians often use several accounts to justify the introduction of the topic, some external (e.g. “the hospital wants it”), some patient-related (e.g. “because of your current physical condition”). There is a relevance paradox: the topic is being framed as ‘relevant in the future’ but ‘needs to be discussed now’. All this leads to the fact that a lot of interactional effort is needed to introduce the topic of care decisions. This study led to three targets to improve care decision discussions 1) an interactional slot has to be created to introduce the care decision topic; 2) common ground has to be created and found; 3) the paradox of the topic as ‘relevant in the future’ but ‘needs to be discussed now’ needs to be overcome. What is patients’ perspective towards care decisions and care decision conversations? The trigger for our qualitative interview study with patients (chapter 4) was the discrepancy in the assessment of the patient education (informative, good overall marks, but at the same time neutral towards its helpfulness). However, the insight into the patients’ perspective towards care decisions provided much more information. The most likely explanation for the discrepancy, is the deep conviction of patients that care decisions are associated with the end of life. Therefore, they thought the information was indeed useful, but not for them at this moment in time. Furthermore, this association with the end of life made the topic sensitive. Another deep conviction this study revealed, was the (mis) conception that care decision conversations lead to definite, fixed choices, which made some patients hesitant towards discussing the topic. It also revealed
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