Chapter 7 156 more frequently at the emergency department, as was observed in chapter 5 and 6. These findings are consistent with physicians statements that the topic is barely discussed at the outpatient clinic and that they mainly have experience with care decision conversations at the emergency department (intermezzos). An explanation for the higher frequency of these conversations at the emergency department could be that the quality standards of the Dutch Association of Internal Medicine (NIV) demand a code status is documented at admission (27). In case the topic was not discussed at the outpatient clinic, these conversations took place at the emergency department. However, a risk of demanded documentation is that the topic is discussed ‘because it had to be registered’ – to ‘tick a box’ on the admission note and sign out – without proper attention to goals and values of the patient (28). Recently, the Dutch Federation of Medical Specialists published a guidance document on when to conduct care decision conversations at the emergency department. It is stated that in the decision to start this conversation, the physician should weight the chance of an acute cardiac arrest and medical meaningfulness of resuscitation. Besides, at least resuscitation should be discussed (29). In this guidance document, as is a common believe in the medical world, the emergency department is often pointed out as the worst place to discuss care decisions, with doom scenarios of seriously ill patients, unable to think clearly, who are overwhelmed by the question whether they want to be resuscitated. We take a more nuanced view. Obviously, a patient can be shocked if the physician suddenly asks “do you want to be resuscitated?”, and purely the resuscitation question may not be relevant and for every patient. However, the broader spectrum care decisions comprehends is relevant. Patients’ goals and values matter – regardless of their risk of a cardiac arrest – and discussing the potential for opting out of further diagnostic or treatment interventions is always appropriate. If this potential is discussed more frequently, this might also reduce the sensitivity of the topic and create common ground over time. In the secondary outcomes of our study at the emergency department (as we discussed in chapter 6) we asked patients what they deemed an appropriate moment to discuss care decisions. Although merely 32% of the patients appointed the emergency department as an appropriate moment, this was still more often than the general practitioner (29%) or an first (15%) of follow-up (14%) outpatient clinic visit. The most appointed
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