7 General discussion and summary 161 Furthermore, we advise future studies that aim to combine video-analysis with other methods to consider incorporating a cascading consent into their methods (e.g. consider to ask for audio-recordings if no consent for videorecordings, and separate consent for other measurements). Besides, it is important to choose the endpoints of the research in this topic carefully. In our opinion not just the frequency (‘tick the box’), but the quality of care decision conversations matter, so we recommend to use outcomes that measure (patient-assessed) quality of communication, or patient satisfaction regarding the specific care decision conversation. Finally, the multiple perspectives we combined in this thesis were very valuable as they triangulated results. The qualitative interviews provided possible explanation for observations we did in the quantitative studies. And because both the physician and patient are necessary in the conversations, it was insightful to deepen our knowledge on both perspectives. On top of that, the combination of medical, educational and communication and linguistics glasses offered important information. We would like to advocate for combining these perspectives and research methods more often, especially within topics in which communication plays a key role as in care decision conversations, but actually in the entire medical world. Future perspectives – clinical practice As we discussed before, the perceived irrelevance is one of the key points to address in order to improve care decision conversations. If the relevance is not seen, these important conversations are not conducted at all. This calls for a change of the care decision narrative. In the current perceptions, care decisions are associated with the end of life, sensitive, leading to binding decisions, overwhelming, and irrelevant. Although it can be argued that there are some outpatient clinic patients in whom care decision conversations can be trivial (e.g. the often cited example ‘30-year old otherwise healthy women with hyperthyroidism’), this is not the case if you approach care decisions in the broad spectrum of alignment of treatment with patients goals and values. Although the consideration of thiamazole vs radioactive iodine vs operation probably is classified as shared decision-making and not care decisions, maybe it should not be that distinct. It can all be seen in a scale from shared decisionmaking (between treatment options) to care decisions (with more emphasis
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