7 General discussion and summary 155 for them to aid the decision of introducing the topic of care decisions further troubled care decision conversations. In chapter 5, we observed the effect of a high pressure situation on increased awareness and therefore probably more perceived relevance. Before our study at the emergency department, we adjusted the interventions for both physicians and patients to emphasize the relevance more and further disconnect the topic of care decisions from the end of life. Despite these adaptations, still 5% of the patients used the ‘other namely’ option to express their feeling an appropriate moment to discuss care decisions was ‘when relevant’. This implies they did not perceive it as relevant now. Remarkable is that literature shows that even patients who are indeed closer to the end of life than the population we studied, still believe they are not there yet and it is too soon (8). It might be discouraging to see that despite several interventions, we were still unable to completely eliminate the end of life association and therefore perceived irrelevance of the topic of care decisions. This is an important challenge. Several behavioral models have described differences in information processing and likelihood of persuasion depending on motivation and perceived relevance (9–18). In order for all information provision and training to be meaningful and to stick, first both patients and physicians must see the relevance. We will further elaborate in this challenge in the future perspectives section. Setting There is a lot of debate about the appropriate setting to discuss care decisions (19–26). At the start of this research, we assumed that the outpatient clinic was a more suitable setting for care decision conversations than the emergency department. An assumption quite common in the medical world and underlined in previous research (20–23,26). Although some advantages of the outpatient clinic are quite obvious (a preexisting physician-patient relationship, calmer environment, ‘time’ as in less pressure to come to an immediate decision), this setting provides multiple challenges as well. In chapter 2 and 3, we showed the number of care decision conversations in the general internal medicine outpatient clinic population is low. Presumably, the dilemma of the perceived irrelevance, that resonates in all our studies, contributes to this low frequency. Surprising to some extent the topic of care decisions is discussed
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