Chapter 3 58 the patient for the ‘what if’ scenario: what if it gets worse. We can also see this as creating common ground: the physician shares the information that matters in making care decisions from a physician perspective [33]. A paradox, however, still remains. The topic is framed as ‘relevant in the future’ but ‘needs to be discussed now’. Elsewhere in our data we also see that the care decisions are framed as not yet relevant (e.g., we see references to it being ‘logical’ not to have discussed this thus far because of the patient’s young age). Although the care decisions become (more) relevant when things get worse, by that point it could also be too late to make certain decisions. At the same time, patients might feel anxious when the topic is brought up in the routine consultation. We call this the relevance paradox. Because the topic is introduced as ‘not yet relevant’ in this example, postponing the actual decision is a logical consequence. In example 1, a logical consequence of the physician introducing care decisions as ‘missing information in the EHR’ is to document the decision in the EHR. 4. Discussion and conclusion 4.1 Discussion After counting in our data how often care decisions were discussed during consultations at the internal medicine outpatient clinic, we used conversation analysis to explore when and how they are discussed. It is striking how few discussions of care decisions took place: the topic was introduced in only 21 of the 150 video-taped consultations. We established there is no destined phase and therefore no interactional slot for the introduction of the topic of care decisions. Because there is no obvious slot, a lot of interactional effort is needed to introduce the topic. Common ground needs to be created and relevance needs to be accounted for. Hesitation markers, repairs and hypothetical talk furthermore show the precariousness of the topic, as confirmed by previous literature. Extensive accounts are provided by both physicians and patients to introduce the topic of care decisions. We have noted a difference in implication between external and patient-related accountability. The data show that there seems to be a dilemma with relevance. General perception is that the care decision conversation becomes relevant when the treatment that is discussed is just around the corner (e.g., an end-oflife setting or acute/severe medical illness). This results in statements like
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