General introduction 15 1 conversations tend to be deferred until either the end of life, evidenced by research primarily focused on end-of-life settings (12,21,32,41,42), or in the ED during acute situations, where there is limited time for thorough discussion and consideration of the patient’s preferences before a decision is made. COVID-19 Our research project took a turn in the year 2020, when the first patient afflicted with COVID-19 was admitted in the Netherlands. This global health crisis, exerting unprecedented stress upon the healthcare system (43–45), inadvertently influenced the trajectory of our research. On the one hand, conducting scientific research was a lot more complicated, as patient contacts (especially for the purpose of doing research) had to be limited. Also the extremely high workload made physicians more hesitant to participate in research. On the other hand, it provided opportunities, as we experienced from medical practice that the high pressure context influenced the awareness for care decision conversations (46–50). This scenario presented us with an exceptional chance to explore the effects of a global pandemic on code status documentation. The research restrictions at the onset of the pandemic made it difficult to investigate the actual care decision conversations, patient satisfaction or (patient assessed) quality of communication like in our other studies. Therefore we look into code status documentation in this research period. Shared decision-making Over the past decades, patient-centered care and shared decision-making have become the ideal models for physician-patient decision-making (51–53). Within the framework of patient-centered care, physicians are encouraged to partner with patients to co-design and deliver personalized care (54–56). Although shared decision-making is not a central part of this thesis, it is irrevocably connected to care decisions. Throughout the project it became clear that physicians as well as patients need tailored support as part of the broader spectrum of shared decision-making. It is surprising that despite the well acknowledged importance of patientcentered care and shared decision-making, both physicians and patients tend to avoid conversations about care decisions. How can we deliver patientcentered care and make shared decisions, if we do not talk about it?
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