She added, “if they [the provider] selleck chemicals llc … reiterated what I told them, I would know they had listened to me. When exploring reactions to the term ‘preference’ it became clear that the term was unclear to participants: “[this term] preferences is not clear” (P13 <45 F), and “I don’t know what preferences would mean in this context” (P15 45–64 M). Many interpreted ‘preference’ as referring to the chosen option rather than referring to individual priorities: “what are my preferences? … in other words he's giving me choices” (P23 ≥65 M) and “… if you had a

number of choices, which [one] would be the one that you prefer” (P25 45–64 M). The term ‘what matters most’ remained the most consistently understood term in this interview stage. Reactions included statements indicating that the term was the same as the things that are buy CHIR-99021 “more personal” (P17 <45 F) and “at the core of my concerns … whether it be future health problems, family, or how I manage at home…” (P20 <45 F), or referred to whether “… one concern

outweighed others? In making a decision, I want to see my child graduate from high school. I want to stay alive as long as I can” (P24 ≥65 F). Nine of 15 participants preferred the phrasing ‘what matters most’, and understood the item to mean “how concerned and how interested … [healthcare professionals were] in what I had to say about my health issues” (P26 ≥65 M). In addition, there was significant evidence in the interviews of resistance toward the adoption of decision making roles when individuals considered how they would react in clinical encounters: “… when someone … knows more than I do, I do really need them to help me choose what is good for me” (P23 ≥65 M), a view also espoused by participant 22: “my preference may not be best, therefore the decision or choice by the professional/the provider is the important thing?” (P22 ≥65 M). As described above the need for this item emerged during our first round of interviews. Participants noted a difference

between providers who listened to ‘what mattered most’ and those who took the extra step to integrate those priorities when making recommendations. Participant 7 asked, “how would I know if he [provider] understood my worries Prostatic acid phosphatase and concerns?” (P7 <45 F). In research terms, we recognized this as the difference between preference elicitation and preference integration. As one participant said, it is the difference between “understanding my concerns” versus also “paying attention to … what I am saying” (P10 <45 M). We therefore recognized the need to develop a new item to address the dimension of preference integration. After brainstorming candidate items, we selected a group of possible phrases (Table 2). We asked participants to respond to the terms ‘work’, ‘involve’, or ‘include’. Participants preferred the term ‘include’ as being a better indication that a patient was being brought “into the whole process” (P25 45–64 M).