Mrs A pursued all active treatment options available to her and withdrew from dialysis

when it was no longer feasible. The achievement of ACP in Mrs A’s case was bringing her and her immediate family to a common understanding with nephrology staff about the seriousness of her medical conditions, her prognosis and the potential scenarios for future deterioration in health, despite a language barrier and a busy family who were not all available during office hours. Knowing that her life expectancy was limited, Mrs A identified and articulated, largely to her family, her personal goals and preferences for care. Her family were able to choose to spend time with her and support her, knowing this might be a limited opportunity. Mrs A’s case shows that these conversations can be difficult but when Endocrinology antagonist ACP is started when the patient is relatively well and out of hospital there is the opportunity to identify misunderstandings, resolve them and PI3K inhibitor move forward. Furthermore there is time for patients to reach a point of readiness to undertake

ACP and identify key decision-makers and personal priorities. Starting ACP early was key to reuniting Mrs A with her son. Mrs A’s ACP also highlights some issues to be aware of when using interpreters. Both Mrs A and her family commented to Dr Y that the skill of interpreters in translating these conversations was variable but unfortunately Dr Y could not consistently secure their preferred interpreter. The better interpreters were able to convey information better than some of Mrs A’s children felt they could. Language barriers within families can be a significant issue for

some, particularly where older patients have children who grew up in New Zealand or Australia and may be more comfortable speaking in English than their parent’s first language. Patients may wait for physicians to initiate end-of-life discussions and may feel uncomfortable asking for prognostic information.[7] Tolmetin Patients may perceive ACP as a health-care professional initiative to limit their future medical treatment, for example because of resource constraints.[3, 9] Patients may not be aware that their condition is life limiting. Family may wait for the patient to initiate end-of-life discussions.[8] Family may be unaware that the patient has a life limiting medical condition. Discussing death can be emotionally distressing for health professionals and skills and/or support for managing this distress are not currently commonly taught to nephrology trainees.[10, 11] The previous experience of emotional distress during end-of-life conversations may cause the health-care professional to avoid future discussions.[10] Lack of available time to hold ACP discussions.[10] Physician perceptions that end-of-life conversations are not valuable to the patient and/or may cause harm by diminishing patient hope.