Recommendations on self-management interventions for adults living with obesity: COMPAR-EU project.

Self-management interventions (SMIs) may improve disease management in adults living with obesity. We formulated evidence-based recommendations for SMIs within the context of the COMPAR-EU project. The multidisciplinary panel selected critical outcomes based on the COMPAR-EU core outcome set and established decision thresholds for each outcome. Recommendations were informed by systematic reviews of effects, cost-effectiveness, and a contextual assessment. To assess the certainty of the evidence and formulate the recommendations, we used the GRADE approach guidance. Overall, SMIs were deemed to have a small impact, but the absence of harmful effects and potential cumulative benefits indicated a favourable balance of effects, despite low certainty. SMIs showed variations in structure, intensity, and resource utilisation, but overall are likely to be cost-effective. Adapting SMIs to local contexts would enhance equity, acceptability, and feasibility, considering patients' values, and availability of resources and teamwork. Consequently, the panel made conditional recommendations favouring SMIs over usual care. The rigorous and explicit recommendations demonstrated the effectiveness of SMIs for adults living with obesity. However, the gaps in the literature influenced the panel to make only conditional recommendations in favour of SMIs. Further research is needed to strengthen the evidence base and improve recommendations' certainty and applicability.

Shared decision-making in undergraduate nursing and medical education: An explorative dual-method study.

OBJECTIVE: This study explores how shared decision-making (SDM) is integrated in undergraduate nursing and medical education. METHODS: A dual-method design was applied. The integration of SDM in medicine and nursing education programs (i.e. SDM on paper) was explored through document analyses; the integration of SDM in curricula (i.e. SDM in class) through interviews with teachers and curriculum coordinators (N = 19). RESULTS: A majority of the education programs featured SDM, mostly non-explicit. In curricula SDM was generally implicitly featured in compulsory courses across all study years. SDM was often integrated into preexisting theories and models and taught through various methods and materials. Generally, teachers and supervisors were not trained in SDM themselves. They assessed students' competence in SDM in a summative manner. CONCLUSION: Overall, SDM was featured in undergraduate nursing and medical education, however, very implicitly.

COMPAR-EU Recommendations on Self-Management Interventions in Type 2 Diabetes Mellitus.

Self-management interventions (SMIs) offer a promising approach to actively engage patients in the management of their chronic diseases. Within the scope of the COMPAR-EU project, our goal is to provide evidence-based recommendations for the utilisation and implementation of SMIs in the care of adult individuals with type 2 diabetes mellitus (T2DM). A multidisciplinary panel of experts, utilising a core outcome set (COS), identified critical outcomes and established effect thresholds for each outcome. The panel formulated recommendations using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach, a transparent and rigorous framework for developing and presenting the best available evidence for the formulation of recommendations. All recommendations are based on systematic reviews (SR) of the effects and of values and preferences, a contextual analysis, and a cost-effectiveness analysis. The COMPAR-EU panel is in favour of using SMIs rather than usual care (UC) alone (conditional, very low certainty of the evidence). Furthermore, the panel specifically is in favour of using ten selected SMIs, rather than UC alone (conditional, low certainty of the evidence), mostly encompassing education, self-monitoring, and behavioural techniques. The panel acknowledges that, for most SMIs, moderate resource requirements exist, and cost-effectiveness analyses do not distinctly favour either the SMI or UC. Additionally, it recognises that SMIs are likely to enhance equity, deeming them acceptable and feasible for implementation.

Contextual factors for the successful implementation of self-management interventions for chronic diseases: A qualitative review of reviews.

OBJECTIVES: To identify and describe the most relevant contextual factors (CFs) from the literature that influence the successful implementation of self-management interventions (SMIs) for patients living with type 2 diabetes mellitus, obesity, COPD and/or heart failure. METHODS: We conducted a qualitative review of reviews. Four databases were searched, 929 reviews were identified, 460 screened and 61 reviews met the inclusion criteria. CFs in this paper are categorized according to the Tailored Implementation for Chronic Diseases framework. RESULTS: A great variety of CFs was identified on several levels, across all four chronic diseases. Most CFs were on the level of the patient, the professional and the interaction level, while less CFs were obtained on the level of the intervention, organization, setting and national level. No differences in main themes of CFs across all four diseases were found. DISCUSSION: For the successful implementation of SMIs, it is crucial to take CFs on several levels into account simultaneously. Person-centered care, by tailoring SMIs to patients' needs and circumstances, may increase the successful uptake, application and implementation of SMIs in real-life practice. The next step will be to identify the most important CFs according to various stakeholders through a group consensus process.

The Effects of Complementary Therapies on Patient-Reported Outcomes: An Overview of Recent Systematic Reviews in Oncology.

Many patients with cancer make use of complementary medicine alongside conventional medicine, but clinicians in oncology often lack the knowledge to adequately advise patients on the evidence base for complementary therapies. This study aims to provide an overview of recently published systematic reviews that assess the effects of complementary therapies on patient-reported health outcomes in patients with cancer. Systematic reviews, including a meta-analysis of at least two randomized controlled trials, were identified from the PubMed, Embase, Cochrane Library, CINAHL and PsycINFO databases. The methodological quality was assessed with AMSTAR 2. One hundred systematic reviews were included. The results suggest that several complementary therapies can improve health outcomes reported by patients with cancer, such as acupuncture to relieve pain, music interventions to reduce anxiety and yoga to improve cancer-related fatigue. The side effects related to complementary therapy use are generally mild. The results remain inconclusive for some intervention-outcome combinations. Many of the included systematic reviews insufficiently assessed the causes and impact of bias in their interpretation of the results. This overview of systematic reviews can support clinicians in counselling their patients on this topic and provide directions for future research and clinical practice guidelines in the field of complementary medicine.

Patients' and informal caregivers' perspectives on self-management interventions for type 2 diabetes mellitus outcomes: a mixed-methods overview of 14 years of reviews.

BACKGROUND: Self-management interventions (SMIs) are core components of high-quality care in type 2 diabetes mellitus (T2DM). We aimed to identify and summarise the scientific evidence exploring the perspectives of patients with T2DM and their informal caregivers on outcomes of SMIs, and the key themes to enhance T2DM patient-centred care. METHODS: We conducted a mixed-methods overview of reviews. We searched MEDLINE, CINAHL and PsycINFO, up to June 2021 for systematic reviews (SRs) exploring the perspectives of adults with T2DM and their informal caregivers, regarding self-management. Two reviewers conducted independently study selection, data extraction and quality assessment. We estimated the degree of overlap across SRs. We performed a qualitative analysis using a thematic synthesis approach. RESULTS: We identified 54 SRs, corresponding to 939 studies, with a slight overlap. Most SRs (47/54, 87%) were considered high quality. We developed summaries for 22 outcomes and identified six overarching themes: (1) diabetic identity; (2) accessing healthcare; (3) experience of care; (4) engagement with self-management; (5) outcomes awareness; and (6) challenges adhering to self-management. We found important variability in how patients with T2DM and their informal caregivers value critical outcomes influenced by the disease progression and several contextual factors. CONCLUSIONS: Our findings represent what matters most to patients with T2DM and their informal caregivers regarding outcomes of SMIs. Our results can facilitate the development and evaluation of SMIs, and guide decision-making in diabetes care, including the formulation of decisions and recommendations.

Identifying most important contextual factors for the implementation of self-management interventions: A Delphi study.

OBJECTIVE: To reach consensus amongst stakeholders about the most important contextual factors (CFs) that may influence the successful implementation of (components of) self-management interventions (SMIs) for type 2 diabetes, obesity, COPD and heart failure. METHODS: Building on our literature review that identified 31 CFs on different levels we conducted a Delphi with 44 stakeholders to identify which of these CFs, or additional ones, contribute most to successful implementation of SMIs. The Delphi consisted of three rounds in which the CFs were scored, prioritized and discussed. RESULTS: The most important CFs overlapped to a great extent across components of SMIs and diseases. Overall, stakeholders identified 'HCP's ability to adapt the advice, communication or intervention to patients' situation and level of knowledge' as most important CF. CONCLUSION: CFs need to be taken into account when implementing promising SMIs. According to stakeholders, the most important CFs are patient-, HCP- or interaction related. 'Tailoring' was selected as the most crucial aspect for HCPs. PRACTICE IMPLICATIONS: Stakeholders can make informed decisions on the adoption of the most suitable SMIs in a given context. These CFs are available through a self-management platform. Suggestions to implement self-management behaviour and to close the research-to-practice gap are made.

Perspectives and Attitudes of Dutch Healthcare Professionals Regarding the Integration of Complementary Medicine in Oncology.

INTRODUCTION: Almost half of all patients with cancer use complementary medicine (CM) alongside conventional cancer treatment. Further integration of CM into clinical practice could enhance communication and ensure improved coordination between complementary medicine and conventional care. This study assessed the perspectives of healthcare professionals on the current status of integration of CM in oncology, as well as their attitudes and beliefs toward CM. METHODS: A convenience, volunteer sample of healthcare providers and healthcare managers working in oncology in the Netherlands were surveyed, using a self-reporting, anonymous, online questionnaire. The perspectives on the current status of integration and barriers to implementing complementary medicine were characterized in part 1, while part 2 assessed respondents' attitudes and beliefs regarding CM. RESULTS: A total of 209 people completed part 1 of the survey and 159 people completed the entire questionnaire. Two-thirds (68.4%) of the respondents indicated that their organization has implemented complementary medicine in oncology, or envisions implementation, while 49.3% stated they were missing something to implement CM in oncology. About 86.8% of the respondents (completely) agreed that complementary medicine is an important supplement to oncological treatment. Female respondents were more likely to express positive attitudes, as well as respondents whose institutions have implemented CM. CONCLUSION: The findings of this study indicate that attention is being paid to the integration of CM into oncology. Overall, the attitudes of respondents toward CM were positive. The main barriers for implementing CM activities were missing knowledge, experience, financial support, and support from management. To improve the ability of healthcare providers to guide patients in their use of complementary medicine, these issues should be delved into in future research.

How is complementary medicine discussed in oncology? Observing real-life communication between clinicians and patients with advanced cancer.

OBJECTIVE: This study aims to examine the structure of communication about complementary medicine (CM) between patients with cancer and clinicians during oncology consultations. METHODS: Previously, consultations between 29 clinicians and 80 patients with advanced cancer were recorded in six hospitals in the Netherlands. The present study considers a secondary analysis. References to CM during the consultation were coded using a self-developed observational coding scheme. RESULTS: At least one reference to CM was observed in 35 out of 80 consultations (44 %), with a total of 73 references. In most cases, CM was initially referred to by patients. Clinicians often did not elaborate on the subject of CM. Relevant aspects related to CM (e.g., safety, effectiveness) were infrequently discussed. Both patients and clinicians showed predominantly neutral to positive attitudes towards CM. CONCLUSIONS: This study shows that patients are still the main initiators of discussions about CM and the topic is not consistently discussed in daily oncology practice. PRACTICE IMPLICATIONS: If exploration of patients' interest in CM or its use became routine in oncology practice, it may relieve patients of the burden of introducing the topic, decrease potential risks of CM use and increase access to evidence-based CM for all patients with cancer.

'A basic understanding'; evaluation of a blended training programme for healthcare providers in hospital-based palliative care to improve communication with patients with limited health literacy.

BACKGROUND: The non-curative setting makes communication and shared decision-making in palliative care extremely demanding. This is even more so for patients with limited health literacy. So far, research in palliative care focusing on shared decision-making with patients with limited health literacy is lacking. Recent research from our team indicates that the assessment of these patients' understanding of their situation and the implementation of shared decision-making in palliative care, needs improvement. METHODS: To improve communication and decision-making, especially with patients with limited health literacy, we developed and evaluated a blended training programme for healthcare providers. The training programme comprised of an e-learning and a team training. The evaluation was performed by 1. conducting interviews (n = 15) focused on evaluating the whole programme and, 2. coding video-recorded outpatient consultations on the extent to which providers involved patients in decision-making before (n = 19) and after (n = 20) the intervention, using the 5-item OPTION coding instrument. RESULTS: The interviews showed that healthcare providers valued the skills they had learned during the e-learning and team training. Providers specifically valued the teach-back technique, learned to use simpler wording and felt better able to recognize patients with limited health literacy. Many providers reported a change in communication behaviour as a consequence of the training programme. Suggestions for improvement for both e-learning and training were, amongst others, a follow-up team training course and a new scenarios for the e-learning about discussing palliative care. For both the pre- and the post-measurement, involving patients in decision-making lies between a minimal and a moderate effort; differences were not significant. CONCLUSIONS: The e-learning and team training were valued positively by the healthcare providers. Adaptations to the e-learning have been made after evaluation. The e-learning has been implemented in several hospitals and medical education. To improve shared decision-making in practice a more sustained effort is needed.

Practices and perspectives of patients and healthcare professionals on shared decision-making in nephrology.

BACKGROUND: Given the complexity and variety in treatment options for advanced chronic kidney disease (CKD), shared decision-making (SDM) can be a challenge. SDM is needed for making decisions that best suit patients' needs and their medical and living situations. SDM might be experienced differently by different stakeholders. This study aimed to explore clinical practice and perspectives on SDM in nephrology from three angles: observers, patients and healthcare professionals (HCPs). METHODS: An explanatory sequential mixed methods design was used. First, in the quantitative part of the study, outpatient consultations with patients with advanced chronic kidney disease (eGFR < 20 ml/min) were video recorded and SDM was assessed using the OPTION5 instrument. Subsequently, in the qualitative part, patients and HCPs reflected on their own SDM behaviour during individual stimulated recall interviews which were analysed using deductive thematic content analysis. RESULTS: Twenty nine consultations were recorded and observed in seven hospitals. The mean SDM score was 51 (range 25-80), indicating that SDM was applied to a moderate extent. The stimulated recall interviews with patients showed that they rely on the information provision and opinion of HCPs, expect consistency and support, and desire a proactive role. They also expect to be questioned by the HCP about their SDM preferences. HCPs said they were willing to incorporate patients' preferences in SDM, as long as there are no medical contraindications. They also prefer patients to take a prominent role in SDM. HCPs ascribe various roles to themselves in supporting patients' decision-making. CONCLUSIONS: Although SDM was applied by HCPs to a moderate extent, improvement is needed, especially in helping patients get the information they need and in making sure that every patient is involved in SDM. This is even more important given the complex nature of the disease and the relatively high prevalence of limited health literacy among patients with chronic kidney disease.

Affective communication with patients with limited health literacy in the palliative phase of COPD or lung cancer: Analysis of video-recorded consultations in outpatient care.

OBJECTIVES: Affective communication in outpatient care is important, especially in the palliative phase. Appropriate responses by healthcare providers to emotional cues or concerns let patients express their feelings and enhance information recall and patient satisfaction. Patients with limited health literacy experience more barriers in health-related communication and information, which makes recognizing their cues and concerns even more relevant. This study explores emotional cues/concerns expressed by patients with limited health literacy and evaluates healthcare providers' responses to these utterances. METHODS: Verona Coding Definitions of Emotional Sequences (VR-CoDES), a consensus-based system for coding patients' expression of emotional distress in medical consultations, was used in this exploratory observational study to analyse affective communication in video-recorded outpatient consultations. Consultations of 18 (10 female, 8 male) COPD or lung cancer patients (aged 70.3±6.8) with limited health literacy were recorded and analysed. Eight healthcare providers in four hospitals participated in the study. RESULTS: 101 cues and 11 concerns were observed, making 6.2 (SD = 4.2) cues or concerns per consultation. Healthcare provider responses were explicit in 56% and left scope for further disclosures in 58% of the cases. Patients with limited health literacy seem to express more cues or concerns than other patient populations. Healthcare providers responded roughly equally often in five different ways, but they shied away from further exploring the emotion disclosed in the cue/concern. Future research should elaborate on these exploratory observations, especially regarding why HCPs often only leave limited space for further disclosure of emotions in palliative care.

Persuasive communication in medical decision-making during consultations with patients with limited health literacy in hospital-based palliative care.

OBJECTIVE: Both patients in the palliative phase of their disease and patients with limited health literacy (LHL) have an increased risk of being influenced by healthcare providers (HCPs) when making decisions. This study aims to explore to what extent persuasive communication occurs during shared decision-making (SDM) by (1) providing an overview of persuasive communication behaviours relevant for medical decision-making and (2) exemplifying these using real-life outpatient consultations. METHODS: An exploratory qualitative design was applied: (1) brief literature review; (2) analysis of verbatim extracts from outpatient consultations and stimulated recall sessions with HCPs; and (3) stakeholder meetings. RESULTS: 24 different persuasive communication behaviours were identified, which can be divided in seven categories: biased presentation of information, authoritative framing, probability framing, illusion of decisional control, normative framing, making assumptions and using emotions or feelings. CONCLUSIONS: Persuasive communication is multi-faceted in outpatient consultations. Although undesirable, it may prove useful in specific situations making it necessary to study the phenomenon more in depth and deepen our understanding of its mechanisms and impact. PRACTICE IMPLICATIONS: Awareness among HCPs about the use of persuasive communication needs to be created through training and education. Also, HCPs need help in providing balanced information.

Towards an open and effective dialogue on complementary medicine in oncology: protocol of patient participatory study 'COMMON'.

INTRODUCTION: Approximately half of patients with cancer use some form of complementary medicine alongside conventional cancer treatment. The topic of complementary medicine often remains undiscussed in consultations between patients with cancer and their healthcare providers. This results in increased risks for adverse or interaction effects and decreased access to the benefits of evidence-based complementary medicine for patients with cancer. This paper describes the design of patient participatory study titled 'COMMON' that aims to explore and enhance open and effective communication about complementary medicine in oncology. The study is carried out in collaboration with 12 (former) patients with breast cancer as coresearchers. METHODS AND ANALYSIS: The study complies with the six steps of the intervention mapping framework. Three non-academic hospitals recruit participants (patients with cancer, oncology healthcare providers and managers) for interviews about the organisation, experiences and needs regarding complementary medicine. To assess communication about complementary medicine, recorded oncology consultations are analysed. For an overview of evidence-based complementary medicine available to patients with cancer, a review of reviews is conducted on the evidence on cancer patient-reported outcomes of complementary medicine frequently used by patients with cancer, supplemented with an online search and survey among organisations and persons providing complementary medicine to patients with cancer. Together, these steps generate input for the development of a toolbox that supports an open and effective discussion on complementary medicine in oncology. In a pilot study, acceptability and usability of the toolbox are assessed among patients with cancer and oncology healthcare providers. Dissemination of the toolbox is covered by the commitment of stakeholder parties. ETHICS AND DISSEMINATION: The Medical Ethics Committee Arnhem-Nijmegen declared the study was exempted from formal approval under the Dutch Medical Research Involving Human Subjects Act. The results will be disseminated through open-access, peer-reviewed publications, stakeholder-reporting and presentations at relevant conferences.

Shared Decision Making in Practice and the Perspectives of Health Care Professionals on Video-Recorded Consultations With Patients With Low Health Literacy in the Palliative Phase of Their Disease.

Introduction. An important goal of palliative care is improving the quality of life of patients and their partners/families. To attain this goal, requirements and preferences of patients need to be discussed, preferably through shared decision making (SDM). This enhances patient autonomy and patient-centeredness, requiring active participation by patients. This is demanding for palliative patients, and even more so for patients with limited health literacy (LHL). This study aimed to examine SDM in practice and assess health care professionals' perspectives on their own SDM. Methods. An explanatory sequential mixed methods design was used. Video recordings were gathered cross-sectionally of palliative care consultations with LHL patients (n = 36) conducted by specialized palliative care clinicians and professionals integrating a palliative approach. The consultations were observed for SDM using the OPTION5 instrument. Potential determinants of SDM were examined using multilevel analysis. Sequentially, stimulated recall interviews were conducted assessing the perspectives of professionals on their SDM (n = 19). Interviews were examined using deductive thematic content analysis. Results. The average SDM score in practice was moderate, varying greatly between professionals, as shown by the multilevel analysis and by varying degrees of perceived patient involvement in SDM mentioned in the interviews. To improve this, professionals recommended 1) continuously discussing all options with patients, 2) allowing time for patients to talk, and 3) using strategic timing for involving patients in SDM. Discussion. The implementation of SDM for people with LHL in palliative care varies in quality and needs improvement. SDM needs to be enhanced in this care domain because decisions are complex and demanding for LHL patients. Future research is needed that focuses on supporting strategies for comprehensible SDM, best practices, and organizational adaptations.

Health literacy, information provision and satisfaction in advanced cancer consultations: two observational studies using level of education as a proxy.

OBJECTIVES: Patients with low health literacy (LHL) might feel less informed and satisfied with provided information than patients with high health literacy (HHL). In the setting of advanced cancer, we explored whether LHL patients, compared with HHL patients are: (1) often less informed, and (2) less satisfied with clinicians' communication (a) in general and (b) following information provision specifically. METHODS: Data from two observational studies using recorded consultations were combined. Clinicians' provided information and patients' health literacy level-defined by educational levels-and satisfaction were measured. Χ2 tests and regression (moderation) analyses assessed the relation between health literacy and information provision, and between information provision and satisfaction, meanwhile exploring moderating influences of health literacy. RESULTS: Of 61 included patients, 25 (41%) had LHL. LHL and HHL patients were equally seldom informed about the disease's incurability (36% vs 42%, p=0.66). LHL patients were more often informed about the option of not pursuing anticancer therapy than HHL patients (28% vs 8%, p=0.04). LHL patients were more satisfied with clinicians' communication than HHL patients (M=9.3 vs M=8.5, p=0.03), especially when the option of no anticancer treatment was discussed (p=0.04). Discussing the disease's incurability did not influence satisfaction levels (p=0.58) for LHL and HHL patients. CONCLUSIONS: LHL patients were not less informed, yet more satisfied than HHL patients. Both groups were equally seldom informed about the disease's incurability. No anticancer therapy was mostly discussed with LHL patients who were more satisfied following this information. Clinicians should be encouraged to inform all patients about the disease status and (non)treatment options, while not overlooking empathic support.

Instrumental and affective communication with patients with limited health literacy in the palliative phase of cancer or COPD.

BACKGROUND: Patients have a 'need to know' (instrumental need) and a 'need to feel known' (affective need). During consultations with patients with limited health literacy (LHL) in the palliative phase of their disease, both the instrumental and the affective communication skills of healthcare providers are important. The study aims to explore instrumental and affective communication between care providers and LHL patients in the palliative phase of COPD or cancer. METHODS: In 2018, consultations between LHL patients in the palliative phase of cancer or COPD and their healthcare providers were video-recorded in four hospitals in the Netherlands. As there was no observation algorithm available for this setting, several items were created to parameterize healthcare providers' instrumental communication (seven items: understanding, patient priorities, medical status, treatment options, treatment consequences, prognosis, and information about emotional distress) and affective communication (six items: hope, support, reassurance, empathy, appreciation, and emotional coping). The degree of each item was recorded for each consultation, with relevant segments of the observation selected and transcribed to support the items. RESULTS: Consultations between 17 care providers and 39 patients were video-recorded and analyzed. Care providers primarily used instrumental communication, most often by giving information about treatment options and assessing patients' care priorities. Care providers assessed patients' understanding of their disease less often. The patients' prognosis was not mentioned in half the consultations. Within the affective domain, the care providers did provide support for their patients; providing hope, reassurance, empathy, and appreciation and discussing emotional coping were observed less often. CONCLUSIONS: Care providers used mostly instrumental communication, especially treatment information, in consultations with LHL patients in the palliative phase of cancer or COPD. Most care providers did not check if the patient understood the information, which is rather crucial, especially given patients' limited level of health literacy. Healthcare providers did provide support for patients, but other expressions of affective communication by care providers were less common. To adapt the communication to LHL patients in palliative care, care providers could be less wordy and reduce the amount of information, use 'teach-back' techniques and pay more attention to affective communication.

Communication and shared decision-making with patients with limited health literacy; helpful strategies, barriers and suggestions for improvement reported by hospital-based palliative care providers.

BACKGROUND: Communication and shared decision-making (SDM) are essential to patient-centered care. Hospital-based palliative care with patients with limited health literacy (LHL) poses particular demands on communication. In this context, patients' emotions and vulnerable condition impact their skills to obtain, understand, process and apply information about health and healthcare even more. If healthcare providers (HCPs) meet these demands, it could enhance communication. In this study, HCPs were interviewed and asked for their strategies, barriers and suggestions for improvement regarding communication and SDM with LHL patients in hospital-based palliative care. METHODS: A qualitative interview study was conducted in 2018 in four Dutch hospitals with 17 HCPs-11 physicians and 6 nurses. Transcripts were analyzed using thematic analysis. RESULTS: In general HCPs recognized limited literacy as a concept, however, they did not recognize limited health literacy. Regarding SDM some HCPs were strong advocates, others did not believe in SDM as a concept and perceived it as unfeasible. Furthermore, five themes, acting as either strategies, barriers or suggestions for improvement emerged from the interviews: 1) time management; 2) HCPs' communication skills; 3) information tailoring; 4) characteristics of patients and significant others; 5) the content of the medical information. CONCLUSIONS: According to HCPs, more time to communicate with their patients could resolve the most prominent barriers emerged from this study. Further research should investigate the organizational possibilities for this and the actual effectiveness of additional time on effective communication and SDM. Additionally, more awareness for the concept of LHL is needed as a precondition for recognizing LHL. Furthermore, future research should be directed towards opportunities for tailoring communication, and the extent to which limited knowledge and complex information affect communication and SDM. This study provides first insights into perspectives of HCPs, indicating directions for research on communication, SDM and LHL in hospital-based palliative care.

Shifts in patients' question-asking behaviour between 2007 and 2016: An observational study of video-recorded general practice consultations.

OBJECTIVE: To gain insight into patient participation in general practice by examining if and how patients' question-asking behaviour has changed over the years (2007-2016). METHODS: A random set of real-life video-recorded consultations collected in 2015-2016 (n = 437) was observed and compared with that of a former study in 2007-2008 (n = 533). Patients' question-asking behaviour was coded using an adapted RIAS protocol containing six categories: medical condition/therapeutic regimen; psychosocial; social context; lifestyle; ask for opinion doctor; practical. GPs and patients completed questionnaires about their background characteristics. Data were analysed using multi-level analysis. RESULTS: Patients asked fewer questions in 2016 than in 2007. The type of question-asking behaviour changed significantly: in particular medical questions decreased while practical questions increased. Less educated patients asked significantly more practical questions than higher educated patients. CONCLUSION: Contrary to our expectations, patients' question-asking has decreased in 2016 compared to 2007, while the average consultation length has increased. The type of questions shifted from medical to practical, especially in less educated patients. It seems that GPs' professional role has expanded over time, since patients nowadays ask their GP more non-medical questions. PRACTICE IMPLICATIONS: GPs probably could continue facilitating patient involvement by more frequently using partnership-building and supportive communication.