"What Is the Most Important to Them?" Swiss Health Care Proxies, Nurses, and Physicians Discuss Planning Practices for Aged Care Residents Who No Longer Have Medical Decision-Making Capacity.

INTRODUCTION: Multiple morbidities, including neurodegenerative diseases such as dementia, which result in diminished decision-making capacity (DMC), make care and care planning complicated for residential aged care facility (RACF) residents. While advance care planning has been highlighted as essential for ensuring that this population receives care that is coherent with their wishes, there are few models specifically designed for this population. This study aimed to explore the current practices for care planning and decision-making for Swiss RACF residents who no longer have medical DMC. METHODS: Semi-structured focus groups were conducted with 23 nurses in three RACFs and with 13 physicians working in 9 RACFs. Semi-structured interviews were conducted with 18 health care proxies of 16 residents without DMC. Thematic analysis was conducted to identify the most salient themes across the dataset. RESULTS: Analyses identified many collaborative processes between nurses, physicians, and health care proxies including family meetings, reconstructing residents' presumed will, making anticipatory decisions, and documenting these decisions. These processes were, however, highly variable and differed between institutions and between residents within each facility, with a lack of standardization. This variability was highlighted to be problematic for information transmission within facilities and in case of hospital or facility transfer. CONCLUSIONS: These results highlight the importance of standardized yet flexible processes of care planning for people who no longer have DMC and provide insights for the development of such models specifically designed to address this problem.

Patient altruism at the end of life: A scoping review.

OBJECTIVES: The concept of altruism is evidenced in various disciplines but remains understudied in end-of-life (EOL) contexts. Patients at the EOL are often seen as passive recipients of care, whereas the altruism of professionals and families receives more research and clinical attention. Our aim was to summarize the state of the scientific literature concerning the concept of patient altruism in EOL contexts. METHODS: In May 2023, we searched 11 databases for scientific literature on patient altruism in EOL contexts in consultation with a health information specialist. The scoping review is reported using the PRISMA checklist for scoping reviews. We used a data charting form to deductively extract data from the selected articles and then mapped data into 4 themes related to our research questions: how authors describe and employ the concept of patient altruism; expressions of patient altruism; consequences of patients' altruistic acts; and possible interventions fostering patient altruism. RESULTS: Excluding duplicates, 2893 articles were retrieved; 33 were included in the final review. Altruism was generally considered as an act or intention oriented toward the benefit of a specific (known) or non-specific (generic) recipient. Patients expressed altruism through care and support, decisions to withhold treatment or actively hasten death, and engagement in advance care planning. Consequences of altruism were categorized in patient-centered (contribution to meaning in life and quality of life), non-patient-centered (leaving a positive impact and saving money), and negative consequences (generating feelings of guilt, exposing individuals with low self-esteem). Interventions to encourage altruism comprised specific interventions, providing opportunities to plan for future care, and recognizing and respecting the patients' altruistic motivations. SIGNIFICANCE OF RESULTS: We identified heterogeneous and limited research conceptualization of patient altruism and its operationalization in palliative care settings. A deeper conceptual, empirical, and theoretical exploration of patient altruism in EOL is necessary.

[Response to the urgent need to train family doctors in geriatrics : residency in long term care facilities]. / Réponse à l'urgence de former les médecins de famille à la gériatrie : l'assistanat en EMS.

Family doctors have to provide the geriatric cares needed by an aging population. In particular, the increased complexity of care needs in the population living in long term care facilities (LCTF) raises several challenges. One of these challenges is the adequate training of physicians working in LCTF as well as the next generation. Residency programs in LTCFs for future general practioners has demonstrated their value abroad. We describe here the creation of a residency program in LTCF for family doctors in Canton Vaud. Since its beginning in 2020, the program has not only trained young physicians but has also improved interprofessionality and strengthened the training of other healthcare professionals.

La population vieillissante requiert des soins gériatriques spécifiques auxquels le médecin de famille doit répondre. De plus, la complexification des besoins en soins de la population en établissement médicosocial (EMS) soulève de multiples défis. Un de ces défis est la formation adéquate des médecins travaillant en EMS et leur relève. A l'étranger, l'expérience de tournus des médecins de famille dans des structures similaires aux EMS a démontré sa pertinence. Nous illustrons ici le contexte et la mise en place d'une formation postgraduée en EMS pour les médecins de famille sur le canton de Vaud et présentons un aperçu des bénéfices de ce programme depuis sa mise en place en 2020 : au-delà de la formation de jeunes médecins, l'assistanat en EMS améliore la collaboration interprofessionnelle et contribue à la formation d'autres professionnels de la santé.

Introducing "A Question That Might, Perhaps, Scare you": How Geriatric Physicians Approach the Discussion About Cardiopulmonary Resuscitation with Hospitalized Patients.

Decisions about the relevance of life-sustaining treatment, such as cardiopulmonary resuscitation (CPR), are commonly made when a patient is admitted to the hospital. This article aims to refine our understanding of how discussions about CPR are introduced, to identify and classify the components frequently occurring in these introductions, and discuss their implications within the overarching activity (discussing CPR). We recorded 43 discussions about CPR between physicians and patients, taking place during the admission interview. We applied an inductive qualitative content analysis and thematic analysis to all the encounter content from the launch of the conversation on CPR to the point at which the physician formulated a question or the patient an answer. We identified this part of the encounter as the "introduction." This systematic method allowed us to code the material, develop and assign themes and subthemes, and quantify it. We identified four major themes in the introductions: (i) agenda setting; (ii) circumstances leading to CPR (subthemes: types of circumstances, personal prognostics of cardiac arrest); (iii) the activity of addressing CPR with the patient (subthemes: routine, constrain, precedence, sensitivity); and (iv) mentioning advance directives. Our findings reveal the elaborate effort that physicians deploy by appealing to combinations of these themes to account for the need to launch conversations about CPR, and highlight how CPR emerges as a sensitive topic.

"Life goes on": Perspectives on the will to live from residents of Swiss long-term care facilities.

OBJECTIVES: While there is a growing body of literature on the wish to die in older patients, there is little research about their will to live. Exploring the subjective will to live (WTL) offers valuable insights into the patients' resources and motivations, which could help improving geriatric palliative care. The aim of this study was to examine, in long-term care facilities (LTCF), residents' definitions of and factors influencing their WTL. METHODS: Twenty residents (mean age 85.8 ± 10.3 years, 70% women) of 3 Swiss LTCFs gave informed consent and participated in semi-structured interviews about their WTL. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was conducted to identify recurrent themes (40% double coded). RESULTS: The majority of residents reported that they had not thought about the WTL. Nevertheless, they had no difficulty in describing it as innate in their lives. They spontaneously mentioned factors that contributed to their WTL, classified into 5 themes: (1) relationships - primarily with family and health professionals, secondarily with other residents; (2) living situation - the LTCF as a necessary place providing care, constant professional presence, and security, yet necessitates inconveniences such as loss of independence; (3) personality factors - positive outlook on life or spirituality; (4) engagement in routines - organized activities and individual daily routines; and (5) health status - primarily related to functional health. SIGNIFICANCE OF RESULTS: Examining WTL provides important insights into elements that are essential to take into account in planning care and promoting well-being in LTCF residents. The themes identified provide important starting points for improving life in LTCFs.

Talking about chronic pain in family settings: a glimpse of older persons' everyday realities.

BACKGROUND: The expression of chronic pain remains a delicate matter for those older persons who suffer from this condition. If many studies highlight the difficulties of putting pain into words, scarce are those that take into account how given social networks can facilitate or prevent its expression. Based on a qualitative study that explores the communication about chronic pain in older persons' social network, this article reports on this key issue of talking about health in later life within family settings and provides clinicians with information about the way older persons with chronic conditions perceive their everyday realities and social relations. METHODS: A multidisciplinary research team (medicine, linguistics and psychology) interviewed 49 persons with chronic pain, all from the French-speaking part of Switzerland, aged 75 and older, without any major cognitive or auditory impairments. After transcription, the interviews were analyzed by combining content and discourse analysis with social network theories. RESULTS: Communication about chronic pain depends significantly on the position of the interlocutors within the family structure, with a preference for direct relatives or individuals with similar difficulties. In social networks, the ability to communicate about chronic pain is both a resource (by allowing older persons to get help or by strengthening interpersonal relations) and a challenge (by threatening their autonomy, social relations or self-esteem). CONCLUSIONS: The study shows the predominance of the nuclear family (partner, children) in communication relating specifically to the everyday management of chronic pain. This state of affairs is, nevertheless, balanced by issues of (loss of) autonomy. These findings, in line with current trends in geriatrics, could benefit future reflections on the scope and limits of including relatives in the care of older patients with chronic conditions.

Decision-making ethics in regards to life-sustaining interventions: when physicians refer to what other patients decide.

BACKGROUND: Health decisions occur in a context with omnipresent social influences. Information concerning what other patients decide may present certain interventions as more desirable than others. OBJECTIVES: To explore how physicians refer to what other people decide in conversations about the relevancy of cardio-pulmonary resuscitation (CPR) or do-not-attempt-resuscitation orders (DNAR). METHODS: We recorded forty-three physician-patient admission interviews taking place in a hospital in French-speaking Switzerland, during which CPR is discussed. Data was analysed with conversation analysis. RESULTS: Reference to what other people decide in regards to CPR is used five times, through reported speech. The reference is generic, and employed as a resource to deal with trouble encountered with the patient's preference, either because it is absent or potentially incompatible with the medical recommendation. In our data, it is a way for physicians to present decisional paths and to steer towards the relevancy of DNAR orders ("Patients tell us 'no futile care'"). By calling out to a sense of membership, it builds towards the patient embracing norms that are associated with a desirable or relevant social group. CONCLUSIONS: Introducing DNAR decisions in terms of what other people opt for is a way for physicians to bring up the eventuality of allowing natural death in a less overt way. Formulating treatment choices in terms of what other people do has implications in terms of supporting autonomous and informed decision making, since it nudges patients towards conformity with what is presented as the most preferable choice on the basis of social norms.

Pain Interventions for people with dementia: a quasi-experimental study.

BACKGROUND: Due to the complexity of the provision of care for people with dementia, pain assessment and management is still considered to be lacking. An optimal way to support frontline staff in providing pain assessment and management for people with dementia living in nursing homes has not yet been identified. The success of supporting interventions seems dependent on contextual factors in the nursing homes. This study, therefore, analyzes the feasibility of a nurse-led training intervention, using repeated on-site case studies, in modifying pain intensity and frequency in people with dementia. METHODS: Using a quasi-experimental design, we undertook a multi-center study of nurse-led training in pain management, with subsequent on-site case studies. Healthcare workers from 3 nursing homes assessed pain in 164 residents with dementia over 147 days. We used mixed-effect growth curve models with spline regression to analyze the data. RESULTS: We found that on-site case studies support frontline staff with pain management and assessment. Repeated reflection in case studies led to significantly longer pain free intervals (from 4.7 at baseline to 37.1 days at second follow-up) and decreased frequency of pain events (OR 0.54 at first follow-up and 0.43 at second follow-up). However no trends regarding pain intensity could be found. Therefore, on-site case studies may be valuable for improving pain frequency and pain-free intervals over time. CONCLUSION: This feasibility study shows the potential of on-site support for frontline nursing home staff. On-site case studies may also affect health outcomes in people with dementia. However, the complexity of dementia care necessitates the management of a broader range of needs. TRIAL REGISTRATION: The study was retrospectively registered on the tenth of January 2017 with the German registry of clinical trials (DRKS00009726).

Implementing advance care planning in early dementia care: results and insights from a pilot interventional trial.

BACKGROUND: Advance care planning (ACP) is particularly appropriate for persons with early dementia (PWED) since it promotes conversations about dementia-specific illness scenarios, addresses inconsistencies between advance directives and patients' observed behavior, emphasizes prospective and relational autonomy, and may be generally consistent with older persons' decision-making needs. However, despite evidence of its benefits, ACP is yet to become widely used among PWED. In this paper, we present a dementia-specific tool developed in Western Switzerland, discuss results of a pilot trial designed to promote ACP among PWED and their relatives, and discuss the feasibility and acceptability of the intervention and the study protocol in prevision of a large scale trial. METHODS: This one-arm pre-post pilot trial consisted of four visits, with visits 2 and 3 being the ACP intervention. Quantitative outcome measures during visit 1 and 4 assessed the aptitude of the intervention to support PWED autonomy and relatives' knowledge of PWED's preferences. Feasibility was explored according to how the recruitment procedure unfurled and based on the necessary revisions to the study protocol and healthcare providers' reason for excluding a PWED from the study. Acceptability was assessed according to pre-post evaluations, difficulties regarding the intervention or trial participation, and pre-post qualitative interviews regarding participants' reasons to participate to the study, satisfaction with the tool and difficulties perceived. RESULTS: The ACP intervention itself was well received by PWED and their relatives that expressed satisfaction with the procedure, especially regarding the opportunity to discuss a sensitive topic with the help of a facilitator. Five main challenges in terms of feasibility were 1) to locate eligible patients, 2) to tailor recruitment procedures to recruitment locations, 3) to adapt inclusion criteria to clinical routines, 4) to engage PWED and their relatives in ACP, and 5) to design a trial that does not burden PWED. Despite these challenges, the intervention increased the number of advance directives, the concordance between PWED's preferences and relatives' decision on their behalf, and relatives' perceived control over healthcare decisions. CONCLUSION: Misconceptions about dementia and ACP, in the patient, relatives, and healthcare providers, combined with structural and institutional challenges, have the power to impede research and implementation of ACP in dementia care. For this reason, we conclude that a large scale trial to test a dementia-specific tool of ACP is currently not feasible in Western Switzerland and should be endorsed in a systemic approach of ACP. TRIAL REGISTRATION: This trial was registered in the database clinicaltrial.gov with the number NCT03615027 .

'It's not magic': A qualitative analysis of geriatric physicians' explanations of cardio-pulmonary resuscitation in hospital admissions.

BACKGROUND: Discussing patient preferences for cardio-pulmonary resuscitation (CPR) is routine in hospital admission for older people. The way the conversation is conducted plays an important role for patient comprehension and the ethics of decision making. OBJECTIVE: The objective was to examine how CPR is explained in geriatric rehabilitation hospital admission interviews, focussing on circumstances in which physicians explain CPR and the content of these explanations. METHOD: We recorded forty-three physician-patient admission interviews taking place in a hospital in French-speaking Switzerland, during which CPR was discussed. Data were analysed in French with thematic and conversation analysis, and the extracts used for publication were translated into English. RESULTS: Mean patient age was 83.7 years; 53.5% were admitted for rehabilitation after surgery or traumatism. CPR was explained in 53.8% of the conversations. Most explanations were brief and concerned the technical procedures, mentioning only rarely potential outcome. With one exception, medical indication and prognosis of CPR did not feature in these explanations. Explanations occurred either before the patient's answer (as part of the question about CPR preferences) or after the patient's answer, generated by patients' indecision, misunderstanding and by the need to clarify answers. DISCUSSION AND CONCLUSIONS: The scarcity and simplicity of CPR explanations highlight a reluctance to have in-depth discussions and reflect the assumption that CPR does not need explaining. Providing patients with accurate information about the outcomes and risks of CPR is incremental for reaching informed decisions and patient-centred care. PATIENT CONTRIBUTION: Patients were involved in the data collection stage of the study.

Life worth living: cross-sectional study on the prevalence and determinants of the wish to die in elderly patients hospitalized in an internal medicine ward.

BACKGROUND: Elderly people frequently express the wish to die: this ranges from a simple wish for a natural death to a more explicit request for death. The frequency of the wish to die and its associated factors have not been assessed in acute hospitalization settings. This study aimed to investigate the prevalence and determinants of the wish to die in elderly (≥65 years) patients hospitalized in an internal medicine ward. METHODS: This cross-sectional study was conducted between 1 May, 2018, and 30 April, 2019, in an acute care internal medicine ward in a Swiss university hospital. Participants were a consecutive sample of 232 patients (44.8% women, 79.3 ± 8.1 years) with no cognitive impairment. Wish to die was assessed using the Schedule of Attitudes toward Hastened Death-senior and the Categories of Attitudes toward Death Occurrence scales. RESULTS: Prevalence of the wish to die was 8.6% (95% confidence interval [CI]: 5.3-13.0). Bivariate analysis showed that patients expressing the wish to die were older (P = .014), had a lower quality of life (P < .001), and showed more depressive symptoms (P = .044). Multivariable analysis showed that increased age was positively (odds ratio [OR] for a 5-year increase: 1.43, 95% CI 0.99-2.04, P = .048) and quality of life negatively (OR: 0.54, 95% CI 0.39-0.75, P < 0.001) associated with the likelihood of wishing to die. Participants did not experience stress during the interview. CONCLUSIONS: Prevalence of the wish to die among elderly patients admitted to an acute hospital setting is low, but highly relevant for clinical practice. Older age increases and better quality of life decreases the likelihood of wishing to die. Discussion of death appears to be well tolerated by patients.

Advance care planning dispositions: the relationship between knowledge and perception.

BACKGROUND: Legal dispositions for advance care planning (ACP) are available but used by a minority of older adults in Switzerland. Some studies found that knowledge of and perception of those dispositions are positively associated with their higher usage. The objective of the present study is to test the hypothesis of an association between increased knowledge of ACP dispositions and a more positive perception of them. METHODS: Data collected in 2014 among 2125 Swiss community-dwellers aged 71 to 80 of the Lausanne cohort 65+ (Lc65+), a population-based longitudinal study on aging and frailty. Data collection was conducted through a questionnaire on knowledge, use and perception of lasting power of attorney, advance directives and designation of a health care proxy. Covariables were extracted from the Lc65+ database. Bivariable and multivariable regression analyses assessed the association between level of knowledge and perception. RESULTS: Half the participants did not know about legal dispositions for ACP; filing rates were 14% for advance directives, 11% for health care proxy and 6% for lasting power of attorney. Level of knowledge about the dispositions was associated with a more positive perception of them, even when adjusting for confounding factors. CONCLUSION: Although the direction of the association's causality needs more investigation, results indicate that better knowledge on ACP dispositions could improve the perception older people have of them. Communication on dispositions should take into account individual knowledge levels and address commonly enunciated barriers that seem to diminish with increased knowledge.

[Content of discussions about cardiopulmonary resuscitation with elderly patients]. / Contenu des discussions concernant la réanimation cardiopulmonaire avec les patients âgés.

Openly talking with caregivers and physicians about medical decisions to prolong life, such as cardiopulmonary resuscitation, offers patients the opportunity to ensure that these decisions will be in line with their values and expectations, and thereby promote their autonomy and responsibility in health care. In order to support -informed and shared decision-making, it is important to share with the patient relevant information concerning their life-threatening condition (including risks of cardiac arrest, risks associated with the resuscitation procedure, immediate and long-term survival, and the impact of the procedure on quality of life), and encourage a -holistic discussion of the goals of care.

Le fait de discuter ouvertement avec leur médecin des décisions médicales concernant la prolongation de la vie, telle la réani­mation cardiopulmonaire, permet aux patients d'être rassurés sur le fait que ces décisions seront en conformité avec leurs ­valeurs et leurs attentes ; ceci favorise ainsi leur autonomie et leur responsabilité dans le projet de soins. Afin de soutenir une prise de décision informée et partagée, il est important de partager avec le patient les informations pertinentes par rapport à son pronostic vital (y compris les risques de subir un arrêt cardiaque, les risques associés à la procédure de réanimation, les chances de survie immédiate et à long terme, et l'impact de la procédure sur la qualité de vie), et d'encourager une discussion globale sur les objectifs des soins.

[Dementia from a palliative care perspective: why a disease-specific advance care planning is necessary]. / Demenz aus palliativmedizinischer Perspektive: warum ein krankheitsspezifisches Advance Care Planning wichtig ist.

Dementia from a palliative care perspective: why a disease-specific advance care planning is necessary Abstract. Palliative Care has to transform profoundly in the context of population aging in many countries around the globe. It has to collaborate increasingly with geriatric medicine and incorporate geriatric expertise. One of the pivotal challenges of geriatric palliative care is ethically appropriate decision making for patients who have lost decision-making capacity. While the traditional approach to advance directives (living wills) has demonstrably proven ineffective, the new approach that is currently being embraced, including in German-speaking countries, is the systemic process of advance care planning (ACP). In this article, ACP is first presented with its general aims, elements and effects. Second, it is shown why we need an adapted ACP program for people with dementia and what such a dementia-specific ACP must entail.

[Prevention of urinary tract infection in the elderly : what's new in long-term care facilities?] / Prévention de l'infection urinaire chez la personne âgée :quoi de neuf dans les établissements médico-sociaux ?

Urinary tract infections are common in the elderly. They are a frequent reason for antibiotic prescription in nursing homes and hospitals. Doctors are confronted daily to the challenge that it is to diagnose urinary tract infections in older patients. The incidence of asymptomatic bacteriuria and the presence of unspecific symptoms and signs in this population transform guidelines for prevention and treatment into some kind of a battle. In this article we will : 1) make a reminder of the particular features of urinary tract infection in the elderly person ; 2) present the recommendations made by the experts and 3) emphasize the prevention of catheter-related urinary tract infection. The latter has already proven itself. We will also focus on the prevention of multi-resistant bacterial infections through the correct use of antibiotics.

L'infection urinaire chez la personne âgée est très fréquente. C'est l'une des causes de prescription d'antibiotiques dans les établissements de long séjour et d'hospitalisation. Son diagnostic chez les patients âgés est un défi quotidien pour les praticiens. La prédominance des bactériuries asymptomatiques et le cortège des signes et symptômes aspécifiques dans cette population font que les recommandations de prévention et de prise en charge deviennent une bataille. Dans cet article, nous allons : 1) faire un rappel de la particularité de l'infection urinaire chez la personne âgée ; 2) présenter les recommandations édictées par les experts et 3) mettre l'accent sur la prévention de l'infection urinaire liée au cathéter. Cette dernière a déjà fait ses preuves. Nous mettrons un accent sur la prévention des infections à bactéries multirésistantes par un juste usage d'antibiotique.

[Resuscitation of elderly people : how to approach their preferences in advance]. / Réanimation des personnes âgées : comment aborder les preferences en amont ?

Cardiopulmonary resuscitation (CPR) is a medical intervention whose practice is highly regulated. In Switzerland, when dealing with elderly patients, physicians decide whether resuscitation would be medically indicated in the case of a cardiorespiratory arrest and discuss it with the patient. The quality of the information provided by the physician during the first encounter with the patient may influence the latter's preferences. However, many studies emphasize the difficulties that hospital physicians face when engaging in this conversation. In order to promote a care provision that is both adequate and respectful of elderly patients, more attention should be devoted to the obstacles that hinder communication on this subject and to the resources available to physicians.

La réanimation cardiopulmonaire est une intervention médicale dont les techniques sont hautement régulées. En Suisse, dès le premier jour d'hospitalisation des patients âgés, les médecins établissent l'indication médicale à la réanimation dans l'éventualité d'un arrêt cardiorespiratoire et en parlent avec le patient. La qualité des informations données par le médecin pendant le premier entretien lors de l'hospitalisation peut influencer les préférences du patient. Pourtant, de nombreuses études soulignent les difficultés qui s'imposent aux médecins hospitaliers s'engageant dans cette discussion. Afin de promouvoir une prise en charge adéquate et respectueuse des personnes âgées, il convient de s'intéresser de plus près aux obstacles qui entravent la communication à ce sujet et aux ressources (existantes et souhaitées) à disposition des médecins.

"If I Become a Vegetable, Then no": A Thematic Analysis of How Patients and Physicians Refer to Prognosis When Discussing Cardiopulmonary Resuscitation.

Background: Documenting decisions about the relevance cardiopulmonary resuscitation (CPR) is a standard practice at hospital admission yet a complex task. Objective: Our aim was to explore how physicians approach and discuss CPR prognosis with older patients recently admitted to a post-acute care unit. Method: We recorded 43 conversations between physicians and patients about the relevancy of CPR that took place at admission at the geriatric rehabilitation service of a Swiss university hospital. Thematic analysis determined (i) who initiated the talk about CPR prognosis, (ii) at what point in the conversation, and (iii) how prognosis was referred to. Results: Prognosis was mentioned in 65% of the conversations. We categorized the content of references to CPR prognosis in five themes: factors determining the prognosis (general health, age, duration of maneuvers); life (association of CPR with life, survival); proximal adverse outcomes (broken ribs, intensive care); long-term adverse outcomes (loss of autonomy, suffering a stroke, pain, generic, uncertainty); and being a burden. Discussion and conclusion: Discussing CPR is important to all patients, including those for whom it is not recommended. Information about CPR prognosis is essential to empower and support patients in expressing their expectations from life-prolonging interventions and attain shared decision-making.

"Do you want us to try to resuscitate?": Conversational practices generating patient decisions regarding cardiopulmonary resuscitation.

OBJECTIVE: To explore how physicians elicit patients' preferences about cardio-pulmonary resuscitation (CPR) during hospital admission interviews. METHODS: Conversation analysis of 37 audio-recorded CPR patient-physician discussions at admission to a geriatric hospital. RESULTS: The most encountered practice is when physicians submit an option to the patient's validation ("do you want us to resuscitate"). Through it, physicians display presuppositions about the patient's preference, which is not elicited as an autonomous contribution. Through open elicitors ("what would you wish"), physicians treat patients as knowledgeable about options and autonomous in determining their preference. A third practice is related to patients delivering their preference in anticipation of the request and is encountered only for choices against CPR. These decisions are revealed as informed and autonomous, and the patient as collaborative. CONCLUSION: The way that physicians elicit patients' preferences about CPR influences the delivery of autonomous and informed decisions. Our findings point to an asymmetry in ways of initiating talk about the possibility of not attempting CPR, potentially exacerbated by the context of admission interviews. PRACTICE IMPLICATIONS: Decisions about the relevancy life-sustaining interventions need an adequate setting in order to allow for patient participation. Our findings have implications for communication training in regard to involving patients in conversations about goals of care.