Addressing possible problems with patients' expectations, plans and decisions for the future: One strategy used by experienced clinicians in advance care planning conversations.

Giving terminally ill people opportunities to participate in advance care planning involves tensions between: endorsing and supporting patients' expectations, plans and decisions, and addressing how realistic these are. The latter risks exerting undue pressure to change plans; undermining autonomy; jeopardising therapeutic relationships. Our objective is to describe how experienced hospice doctors raise potential/actual problems with patients' expectations, plans or decisions. Conversation analysis of video-recorded consultations between five UK hospice consultants, 37 patients and their companions. Eleven episodes involving five doctors were found. In all of these we identified a 'Hypothetical Scenario Sequence' where doctors raise a hypothetical future scenario wherein current plans/expectations turn out to be problematic, then engage patients in discussing what could be done about this. We describe features of this sequence and how it can circumvent the risks of addressing problems with patients' expectations and plans. Our research breaks new ground, showing that by treating expectations, plans and decisions as potentially not actually problematic, practitioners can recognise and support patients' preferences whilst preparing them for possible difficulties and inevitable uncertainties. Where professionals judge it appropriate to raise problems about patients' preferences, plans and decisions, this sequence can manage the associated risks.

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