Discussing care decisions at the internal medicine outpatient clinic: A conversation analysis

Physicians' training and patient education initiative to improve quality of care decision communication at the emergency department

BACKGROUND

Discussions about care decisions, including code status documentation and advance care planning, are crucial components of patient-centred care. However, due to numerous barriers, these discussions are often avoided by both physicians and patients. As a result, these discussions often take place at the emergency department (ED). We aimed to improve the quality of care decision conversations in the internal medicine ED.

METHODS

This pre-post intervention study was conducted at the internal medicine ED of a tertiary hospital in the Netherlands. Two interventions were implemented simultaneously: physician training and patient education. Physician training included an e-learning module and simulated patient sessions. Patients received a leaflet providing information about care decisions. Primary outcome was patient satisfaction with the care decision discussions, assessed using the Quality of Communication questionnaire. Secondary outcomes included the percentage of patients recalling a care decision discussion, initiator of the discussion, leaflet recall, leaflet evaluation, prior care decision discussions and perceived appropriate timing for discussions.

RESULTS

333 patients participated, 149 before and 184 after the interventions. Postintervention, there were significant improvements in patient-reported quality of care decision communication (p<0.001) and more patients recalled having care decision discussions (63.7% vs 45.9%, p=0.001). However, only 12% of patients recalled receiving the leaflet.

CONCLUSIONS

Implementation of physician training and patient education significantly improved the quality of care decision conversations in our internal medicine ED. Despite low leaflet recall, the interventions demonstrated a notable impact on patient satisfaction with care decision discussions. Future research could explore alternative patient education methods and involve other healthcare professionals in initiating discussions. These findings underscore the importance of ongoing efforts to enhance communication in healthcare settings, particularly in emergency care.

Childbirth as Fault Lines: Justifications in Physician-Patient Interactions About Postnatal Rehabilitation

Research on justifications has shown their significance in advice-giving, decision-making and children disputes. However, the majority of studies gloss over practical functions of justifications in patient-physician interactions as they are often expected and pursued by patients and in turn, are adopted by physicians to support their stance and authority. This study, through conversation analysis (CA), aims to explore a) what are pragmatic functions of justifications in patient-physician interaction? b) how and when do physicians unfold their justifications for treatment recommendations? c) how do physicians deal with different responses based on their epistemic and deontic domains?. A total of 32 video-recordings between postpartum women and physicians are collected and studied. Four pragmatic functions of justifications drawn upon by physicians are explored: justifications as face-saving, reassurance, risk discussion and clarification-seeking. Despite physicians' attempts to justify their positions as less challenged by patients, this is not the entire picture as they demonstrate their desire to resolve patients' concerns and coordinate their viewpoints to achieve the best practice that facilitates patients' well-being.

Finding the balance between person-centred and treatment-centred discussions in advance care planning-a qualitative analysis of conversations within the MUTUAL (Multidisciplinary Timely Undertaken Advance Care Planning conversations) intervention using a narrative analysis

INTRODUCTION

Advance care planning (ACP) aims to create conditions for more person-centred care. We aimed to explore variations in person-centred care discussions and treatment-centred care discussions within ACP conversations in the Multidisciplinary Timely Undertaken Advance Care Planning (MUTUAL) intervention and how person-centred care discussions could be encouraged. The MUTUAL intervention consists of the following: (i) timely patient selection, (ii) the patient and healthcare professionals preparing for the conversation, (iii) a scripted ACP conversation in a multidisciplinary setting and (iv) documentation.

METHODS

We conducted a narrative analysis of ACP conversations. A narrative summary template was created and used to analyse 18 audio-recordings.

RESULTS

We noticed variations in person-centred and treatment-centred focus within the ACP conversations. We identified three important strategies that facilitated person-centred care discussions within ACP conversations. First, healthcare professionals' acceptance that ACP is an individual process. We believe it is important that healthcare professionals recognise and accept where the patient is in his or her individual ACP process; not making decisions right away can also be part of a decisional process. Secondly, exploring the underlying motivation for treatment wishes can give insights into patient's wishes, values and needs. Lastly, healthcare professionals who demonstrated an adaptive, curious and engaged attitude throughout the ACP process achieved more person-centred ACP conversations. This coincided with elaborating on the patient's emotions, fears and worries.

CONCLUSION

Person-centred and treatment-centred focus varied within the ACP conversations in the MUTUAL intervention. Certain strategies by healthcare professionals facilitated a more person-centred focus.

A patient's perspective on care decisions: a qualitative interview study

BACKGROUND AND OBJECTIVES

Discussing treatment wishes and limitations during medical consultations aims to enable patients to define goals and preferences for future care. Patients and physicians, however, face multiple barriers, resulting in postponing or avoiding the conversation. The aim of this study was to explore an internal medicine outpatient clinic population's perception on (discussing) treatment wishes and limitations.

METHODS

Semi-structured interviews were conducted in two rounds with 44 internal medicine outpatient clinic patients at the University Medical Centre Utrecht, a tertiary care teaching medical centre in the Netherlands. Interviews were transcribed verbatim and thematically analysed with a phenomenological approach and inductive, data-driven coding.

RESULTS

Four themes were identified, two (1-2) represent a deep conviction, two (3-4) are practically oriented: (1) patients associate treatment wishes and limitations with the end-of-life, making it sensitive and currently irrelevant, (2) patients assume this process leads to fixed choices, whilst their wishes might be situation dependent, (3) treatment wishes and limitations are about balancing whether a treatment 'is worth it', in which several subthemes carry weight, (4) the physician is assigned a key role.

CONCLUSION AND PRACTICE IMPLICATIONS

The themes provide starting points for future interventions. It should be emphasized that care decisions are a continuous, dynamic process, relevant at any time in any circumstance and the physician should be aware of his/her key role.

The effect of physician training and patient education on the discussion of care decisions at the internal medicine outpatient clinic

BACKGROUND

Care decision discussions are intended to align treatment with the patient's wishes, goals and values. To overcome the numerous barriers to such discussions, physicians as well as patients need tailored support. We evaluate the effect of a physicians' training and a conversation aid for patients about care decisions on patient and physician outcomes.

METHODS

At the internal medicine outpatient clinic of the University Medical Centre Utrecht, a 1:1 randomized, parallel-group study (patient conversation aid) was combined with a pre-post intervention (physicians' training) design. Primary outcome was patient satisfaction, secondary outcomes were patient-doctor relationship, shared-decision-making, doctor preparedness and patient appreciation of the conversation aid.

RESULTS

Between October 2018 and February 2020 11 physicians (36% residents, 73% female) and 185 patients (median age 58 years (interquartile range (IQR) 50-68), 60% male) participated. Only 28% of the patients reported a care decision discussion during the consultation. We found no effect of the interventions on patient satisfaction (effect sizes -0.14 (95% confidence interval (CI) -0.56-0.27) for conversation aid; 0.04 (95% CI -0.40-0.48) for physician's training), nor on the patient-doctor relationship or shared-decision-making. However, physicians felt more prepared to discuss care decisions after training (median 3 (IQR 1-4) vs 1 (IQR 0-3), p = 0.015). Patients assessed the conversation aid informative and gave an overall mark of median 7 (IQR 7-8).

CONCLUSIONS

First steps towards fruitful discussions about care decisions were made: patients considered the conversation aid informative and physicians felt better prepared to discuss care decisions after training. The low number of care decision conversations patients reported shows exactly how important it is to focus on interventions that facilitate these discussions, for both the patient and physician. Further work needs to be done to establish the best way to empower patients and physicians.

TRIAL REGISTRATION

Dutch trial register, trial 6998 (NTR 7188), registered 04/05/2018, https://www.trialregister.nl/trial/6998 .