2 The effect of training and education at the outpatient clinic 27 1. Background The nationwide ‘Choosing Wisely’ campaign started in the USA in 2012 to engage physicians and patients in conversations about unnecessary tests, treatments and procedures, hereby contributing to appropriate healthcare (1). Following this, the Dutch Association of Internal Medicine published a list of 10 ‘Wise Choices’. One of these ‘Wise Choices’ is to discuss care decisions when talking to patients about their treatment (2). We define care decisions as discussions to align treatment with the patient’s wishes, goals and values, in which the option could also be to waive treatment or further investigation or to put limits to this (e.g. mechanical ventilation, dialysis, tube feeding). This includes for instance code status discussions and advanced care planning (ACP). Although the international consensus definition of ACP as posed by Rietjens et al. corresponds greatly with our vision on care decisions (3), the term ACP is strongly associated with the end of life, mostly due to the extensive research in end-of-life settings (4). To avoid this association, we choose to use the term care decisions throughout this paper. There are numerous barriers for both physicians and patients to discuss care decisions. Barriers for physicians described in literature are for instance: feeling unskilled or inadequately trained; discomfort and fear of complaints (5). On top of that, physicians often wrongfully assume that patients do not want to discuss care decisions (6–8). Patients face other difficulties, such as a lack of knowledge, unawareness of patients of the relevance, and the expectation that physicians will initiate the discussion when needed (4,9). When both parties avoid talking about care decisions, these discussions do not take place in time (10). Consequently, the opportunity to adapt treatment to align with patient’s wishes is often missed (11). Also, this results in situations in which these discussions have to be conducted in far from ideal circumstances, such as in the acute setting at the emergency department with limited time and an acutely ill patient (12). To overcome these barriers and make way for fruitful discussions about care decisions, physicians as well as patients need tailored support. For this study, we aimed to evaluate the effect of a training for physicians and a conversation aid for patients about the topic of care decisions. We measured
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