3 Conversation analysis of authentic care decision conversations 59 ‘it is actually not yet relevant’, it is discussed ‘just to fill the EHR’, or it is discussed ‘because of study participation’, with diverse consequences. Such statements all attempt to create relevance while contradictory sustaining the ‘not actually relevant yet’ perception. In order for the patient to make a considered decision, it is relevant to have these conversations at an earlier moment during regular consultations. Discussing care decisions is relevant far before a decision is made. Therefore, physicians have a difficult task in negotiating the conflicting demands of addressing a precarious topic at a time it is not perceived necessary yet. In 2014, Parry et al. published a systematic review synthesizing observational evidence about patients-physician communication about future illness progression and end-of-life, summarized as ‘sensitive future matters’ [16]. Although our research takes place in a different context, i.e. a general internal medicine outpatient clinic and not an end-of-life setting, some observations are similar. Parry et al. also observed the occurrence of delays, hesitations, and repeats and the use of “hypothetical questions and talk”. In addition, their “framing of the difficult issue as universal or general rather than individual to this patient” corresponds to the use of external accountability in our study (participation in the study or ‘the system’), and their “linking questions and proposals to what the patient had said or not said” corresponds to the use of patient-related accountability in our study. Indirectness, allusive talk, euphemisms, fishing questions and shifting to the positive [16] were less common in our data, probably because of the different setting. This study has various strengths and limitations. One of its major strengths is that we focused on care decision conversations in a general outpatient clinic. So far, most research on this topic has been conducted in end-of-life settings [6,11,15–17] despite calls to conduct these conversations at an earlier stage [2,10,18]. Furthermore, we not only assessed whether a conversation about care decisions in fact occurred but explored when and how these conversations were conducted in this population. Our analysis revealed practices and dilemma’s common in our data and their implications, which will be useful in future training. The low frequency of consultations involving a discussion of care decisions shows the importance of this study and the need for further training and education, but it also limited the number of consultations we were able to
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