Any general preferences should be elicited and recorded. Clinicians would need to encourage increased direct communication between patient and surrogate and support the patient by offering to facilitate such conversations. The annual Medicare wellness visit as recently proposed would have created an opportunity to accomplish at least a starter conversation with patients while being reimbursed for doing so [36].

It may be helpful for patients to know that surrogates may feel burdened by deciding for others. Some patients view allowing others to make decisions for them as an act of love or sign of trust and might be quite surprised to know that not every surrogate welcomes this role. EOL care planning with Avoiders Ibrutinib ic50 is difficult as they may be resistant to interventions to encourage EOL planning, and respect for autonomy includes allowing patients to not make decisions. It may suffice to remind such patients of the importance of decision-making and the major risk of not doing so, receiving life-sustaining treatment by default, which the patient may or may not want. The physician can also inform such patients that not making EOL decisions can result in preventable stress for surrogate decision makers [32], [33], [34] and [35].

Avoiders may not welcome such discussions and they may even be unfruitful and risk PF2341066 harm to the patient–physician relationship. Clinicians should make every effort to accurately discern in which variant their patient belongs, and at regular intervals briefly re-evaluate whether the patient may now be more open to engage in a conversation about EOL care planning. The principal investigator and all co-authors have no conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript. The authors thank all patients who participated in our focus groups, and JoLynn Mikow, Ph.D., for moderating some

of the focus groups. This project was supported by the Department of Veterans Affairs, Veterans Health Administration, Etomidate Health Services Research and Development Service, IIR – 02-224. Dr. Braun was also supported by a Geriatric Academic Career Award, KO1HP20480 through the Health Resources and Services Administration (HRSA). This manuscript was written in the course of employment by the United States Government and it is not subject to copyright in the United States. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or HRSA. Preliminary results of this study were presented in part at the Annual Scientific Meeting of the American Geriatric Society in Orlando, FL. “
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