7 General discussion and summary 149 the key role patients assign to the physician, namely that physicians should determine when it is relevant, initiate the conversation, provide information, explore patients’ thoughts and communicate in an empathetic and sensitive manner. More practically orientated, patients stated that care decisions were about whether a treatment is worth it, a balancing scale in which several elements carry weight. Our patient education provided information on the relevance of care decision conversations, that the conversation is more than the resuscitation question and that the decisions are not fixed and can be adjusted over time. This study taught us that just providing information in a patient education is insufficient to eradicate the deep convictions of patients that care decisions conversations belong to the end of life and leads to fixed choices. Though, it is precisely these convictions that must be overcome in order to engage patients in care decision conversations. This study also partly answers the question: “Why are care decision conversations not conducted more often at the outpatient clinic?”. Patients do not frequently initiate the conversation because they believe the physician should. Furthermore, there is a persistent belief that it is (apparently) irrelevant if the physician does not initiate the conversation. What is the physicians’ perspective towards care decisions and care decision conversations? In three intermezzos, running throughout this thesis, we showed the findings of a qualitative study using semi-structured interviews with physicians. This study, despite limitations such as a small sample size and convenience sampling, provided insights that were very recognizable and triangulated the results from our other studies, described in the main chapters. Physicians themselves also stated care decisions were not discussed regularly at the outpatient clinic, as we detected in chapter 2 and 3. Furthermore, similar to the findings of our conversation analysis in chapter 3, physicians indicated that they must exert considerable interactional effort and provide justifications for introducing the topic of care decisions. Although they call it different. Physicians express the difficulty to bring up the topic if there is no ‘direct cause’, and search for a ‘hook’ to start the conversation. These ‘hooks’ (e.g. study participation, a recent event, patients condition) are exactly the same as what is called accounts in conversational analytic terms. Physicians agree with patients that the physician should initiate the conversation, but whilst
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