3 Conversation analysis of authentic care decision conversations 47 1. Introduction In 2014, the Dutch Association of Internal Medicine published a list of ten ‘Wise Choices’ in internal medicine as part of the nationwide ‘Choosing Wisely Campaign’ [1–5]. One of these ‘Wise Choices’ is for doctors to discuss care decisions when talking to patients about their treatment [2]. Care decisions comprise a broad spectrum of topics, including discussions of code status and do-not-resuscitate orders as well as advanced care planning (ACP). In this paper, we focus on patient-physician communication about code status (patient preferences regarding resuscitation, mechanical ventilation and Intensive Care admission) and other possible treatment options such as dialysis, hospital admission and tube feeding. Previous research has shown that both patients and physicians find care decisions a precarious topic that they tend to avoid [6]. Despite numerous barriers for physicians and patients (e.g. feeling unskilled; unawareness of the relevance[7–11]), care decisions should be a regular part of patient-physician communication [2] and patients should be engaged in the decision-making process [12,13]. It is argued that timely discussions of care decisions can lead to care that is more closely aligned with patient preferences and involves less health care consumption [14]. This topic is, however, often postponed until the end of life, reflected in the fact that research is conducted predominantly in end-of-life settings [6,11,15–17]. If such discussions are not timely, they take place in far from ideal circumstances, such as an acute setting in the emergency department when time is limited and the patient is severely ill [10]. The outpatient clinic, where patients often consult a familiar physician, seems better suited to such conversations [18]. In this paper, we examine videotaped consultations at the internal medicine outpatient clinic. We counted how often care decision conversations occurred within our data. Using conversation analysis (for an explanation of conversation analysis see [19]; for an example, see Erkelens et al. (2020) [20]), we then analyzed when (in which phase of the consultations) and how the topic of care decisions is introduced. Insight in these patterns could be used to guide future practices.
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