Chapter 7 150 patients assume the physicians knows best when it is ‘relevant’ to start the conversation, physicians state they do not know what the appropriate timing and place is either (chapter 4, intermezzos). They struggle with relevance and express the lack of general criteria, national or hospital guidelines on when to discuss the topic. This relevance paradox was seen in the video-recorded consultations as well (chapter 3). Physicians expressed other difficulties as well. They perceive it is a sensitive topic and they feel a lack of control in not knowing how the patient will respond. Besides, cultural differences complicate care decision conversations. It is striking that time is a barrier, but on the other hand sometimes misused as an ‘easy excuse’ not to discuss care decisions. On top of that, some argued the responsibility for care decision conversations should be with the general practitioner. Related to this, the insufficient exchange of information between general practitioners and hospital physicians was pointed out as well. All these barriers further explain why physicians do not initiate care decision conversations more often at the outpatient clinic. This completes the answer to the question “Why are care decision conversations not conducted more often at the outpatient clinic?”. Physicians named some facilitators to care decision conversations as well namely feeling competent and skilled, an informed patient, and awareness amongst themselves, the patients and the public in general. These insights in the physicians perspective towards care decisions reaffirmed targets to improve care decision conversations and brought up new areas to study. What is the effect of a high-pressure situation on care decisions? In March 2020, the COVID-19 pandemic reached the Netherlands. Since this affected pretty much everything and everyone, so did it affect our research. The pandemic put tremendous pressure on patient care and hospital capacity, especially on the ICU. Reports from the frontline indicated an uptick in discussions surrounding ‘code status’. To objectify these rumblings of more attention to code status, we compared code status documentation in a cohort of COVID-19 patients to code status documentation in a cohort of infectious patients before the COVID-19 pandemic in chapter 5. Since the two existing cohorts were essentially different, we compared them descriptively and no statistical analysis was performed. We found similar frequencies of code
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