7 General discussion and summary 153 appropriate moment to discuss care decisions. Although only 32% appointed the emergency department, this was even more than the 29% that appointed the general practitioner and 15% and 14% that appointed the outpatient clinic (first and follow-up visit respectively). The most appointed moment was during an admission at the ward (44%). Noticeable was a reasonable amount of patients (5%) that used the ‘other, namely’ option to express their opinion ‘when relevant’. This study showed us that physicians’ training and patient education can improve care decision conversations at the emergency department. Limitations In addition to specific limitations in the various chapters, there are some limitations to the research in this thesis in general. We would like to point out two of them. First, the patient education, research questionnaires and interviews were all in Dutch. This hindered the participation of patients with insufficient command of the Dutch language. Therefore, the results cannot be extended to these patient groups. This is unfortunate, as it is presumable that these patients more often have a different cultural background and physician named that as a complicating factor in care decision conversations. Second, it can be debated why our interventions showed a significant improvement at the emergency department, but did not at the outpatient clinic. We made several adaptions to the interventions and used a more specific outcome measurement. Therefore, we cannot conclude whether the adaptations made the interventions more effective, interventions are more useful at the emergency department than at the outpatient clinic, or we were able to measure the effect at the emergency department because of the more specific outcome measurement. Possibly the interventions did have an effect at the outpatient clinic as well, but we were unable to measure it in overall satisfaction. Despite this limitation, we underline the decision to make the adaptations, because the implementation of the lessons we learned helped us to answer our research question.
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