TABLE 4.

Theme: Practitioner‐driven – Lost in translation

Quote	Exemplar passages from notes	Note title; setting; service
4a	[Patient] is a difficult patient to interpret, he clearly does not wish to pursue work up of cancer and is cognizant that this may impact life expectancy. In fact, this morning [patient] reported he was “ready to leave this world” and did not want aggressive medical intervention. He stated he was no suicidal and did not want complete removal of medical therapy at this time. He wants to continue with dialysis, yet he clearly states multiple times he does not wish to prolong things. I offered him palliative care consultation and explained to him what those services were about, he refused to see palliative care and did not wish to pursue end‐of‐life care.	Progress; Inpatient; Medicine
4b	Had a lengthy conversation with [patient] about refusing hemodialysis. He was sitting at side of bed and acknowledged that he refused dialysis but when asked why, he does not have an answer. He continues to say that he does not like needles.	Progress; Community Living Center; Long‐term Care
4c	He is able to articulate what would happen if he stopped dialysis, “I will die,” and he is able to articulate what might happen if he continues to not take his medicines, “I might die,” but is unable to explain why he would want to continue dialysis and not take his medicines…He cannot articulate higher level concepts regarding his health such as diet management, what his actual goals are other than, “I want to live,” he cannot connect the dots between saying “I want to live” and doing things that actually might prevent that.	Consult; Inpatient; Palliative Care
4d	[patient] unfortunately has only a basic grasp on his medical problems and diagnosis. He does know that he has pancreatic cancer that is in his belly. When told it was incurable, he asked if “juice” could help.	Consult; Inpatient; Hematology and Oncology
4e	I explained my concern with her that the infection is not going to be curable, especially without surgical intervention. She became very upset stating she did not want me to mention another surgery at this time…When I asked what are her goals of care, she did not understand my questions…I explained to her a few different options depending on her overall goals of care…[Patient] is not ready to discuss an option that does not involve being in the hospital (or a nursing home) for antibiotic therapy.	Progress; Inpatient; Medicine
4f	He tells me if he cannot get a [kidney transplant] then “I am done,” meaning he wants to stop dialysis…He did a 5K walk at [place] and met [celebrity]. He tells me it was the best day of his life…He bought [sport team] season tickets for next year. I decided not to point out the inconsistency of buying season tickets and wanting to stop dialysis…We discuss stopping dialysis each time, but each time he describes a nice quality of life and enjoying himself.	Progress; Outpatient; Geriatric Medicine
4 g	Call to [city] policy to do a wellness check on veteran. Per officer, veteran “sounded fine.” The officer states that veteran feels dialysis is making him sick and states also that he has concerns about the fluid that is taken out during dialysis treatments. Veteran is also reported to have said he feels his concerns are not being listened to. I called his listed number today and asked for him to call back to discuss his goals of care and care plan.	Telephone; Dialysis Unit; Nephrology

Abbreviations: LST, life‐sustaining treatment; CPR, cardiopulmonary resuscitation; DNR, do not resuscitate; HD, hemodialysis; IV, intravenous.