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J Gen Intern Med. 2012 Apr;27(4):445-51. doi: 10.1007/s11606-011-1917-0. Epub 2011 Oct 25.

Missed opportunities for advance care planning communication during outpatient clinic visits.

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Center for the Study of Healthcare Provider Behavior, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA 90064, USA.



Early provider-patient communication about future care is critical for patients with heart failure (HF); however, advance care planning (ACP) discussions are often avoided or occur too late to usefully inform care over the course of the disease.


To identify opportunities for physicians to engage in ACP discussions and to characterize physicians' responses to these opportunities.


Qualitative study of audio-recorded outpatient clinic visits.


Fifty-two patients ≥ 65 years recently hospitalized for HF with one or more post-discharge follow-up outpatient visits, and their physicians (n = 44), at two Veterans Affairs Medical Centers.


Using content analysis methods, we analyzed and coded transcripts of outpatient follow-up visits for 1) patient statements pertaining to their future health or their future physical, psychosocial and spiritual/existential care needs, and 2) subsequent physician responses to patient statements, using an iterative consensus-based coding process.


In 13 of 71 consultations, patients expressed concerns, questions, and thoughts regarding their future care that gave providers opportunities to engage in an ACP discussion. The majority of these opportunities (84%) were missed by physicians. Instead, physicians responded by terminating the conversation, hedging their responses, denying the patient's expressed emotion, or inadequately acknowledging the sentiment underlying the patient's statement.


Physicians often missed the opportunity to engage in ACP despite openers patients provided that could have prompted such discussions. Communication training efforts should focus on helping physicians identify patient openers and providing a toolbox to encourage appropriate physician responses; in order to successfully leverage opportunities to engage in ACP discussions.

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