What makes serious illness conversations acceptable? A mixed-methods study of patient and caregiver experiences in oncology and cardiology

Abstract

Objectives

This study aimed to identify how contextual, dispositional, and relational factors intersect to shape the participant experience of serious illness conversations (SICs) while exploring the nuances of appraisal across different clinical specialties.

Methods

A convergent parallel mixed-methods study was conducted as part of a Serious Illness Care Programme pilot at two Singaporean tertiary centres. Participants with advanced cancer or heart failure were recruited from oncology, cardiology, and palliative medicine clinics. We conducted semi-structured interviews and a Patient Experience Survey (PES) that explored participants views on their communication experience. .Qualitative data were analysed via a case-based thematic approach. Findings were summarized by coders into experience categories of “Good,” “Moderate,” or “Poor.” Quantitative comparisons between patient-reported PES scores and coder-assigned ratings were performed using the Kruskal-Wallis rank-sum test.

Results

Forty participants were recruited (33 patients, 7 caregivers), with 32 (26 patients, 6 caregivers) completing interviews, and 24 patients completing the PES. Among interviewed patients, 19 had advanced cancer and 7 had heart failure. While 96% of patients rated their SICs as “mostly” or “extremely” worthwhile in the PES, qualitative analysis revealed a complex landscape of acceptance, ambivalence, and distress. Discrepancies between patient-reported and coder-assigned ratings indicated that participants appraised encounters as “Worthwhile” even when experiencing significant distress. Four themes were identified as primary influences on participant experience: subjective illness understandings, clinician conversational practices, personal readiness, and relational dynamics. The analysis suggests that trust established through longitudinal therapeutic relationships functioned as a buffer against negative appraisals, offer a possible explanation for why “Worthwhile” scores remained largely experience-invariant.

Conclusion

This study demonstrates that SIC acceptability is a dynamic appraisal refracted through subjective illness understandings and relational contexts. Future research should investigate specific communicative mechanisms that foster affective readiness and rapport, ensuring that serious illness communication aligns with, rather than disrupts, patient and caregiver expectations of healthcare communication.

Plain language summary

This study explored how patients with advanced cancer or heart failure and their family caregivers experience structured goals-of-care discussions known as Serious Illness Conversations (SICs). Researchers at two medical centers in Singapore interviewed 32 participants and collected surveys from 24 patients to understand what factors make these sensitive discussions acceptable and how they impact the people involved. The findings revealed a contrast between what participants reported on paper and what they shared in person. While 96% of patients officially rated the conversations as “mostly” or “extremely” worthwhile in surveys, the interviews revealed a much deeper landscape of ambivalence and emotional pain. We identified a specific phenomenon where participants appraised the encounters as valuable and beneficial even when the experience itself caused them significant distress. This suggests that patients may retrospectively rationalise an upsetting conversation as clinically necessary because they have a strong, trusting relationship with their clinician. In these cases, the long-term bond between the patient and the clinician acts as a vital buffer that protects the patient from the negative emotional impact of discussing their decline. The research further highlighted that a patient’s specific diagnosis influences how they make sense of these clinical inquiries. For those living with heart failure, the condition was often seen as a manageable, long-term problem, which led many to feel that a serious talk about the end of life was premature or unnecessary. Conversely, for many cancer patients, the conversation was often viewed as a frightening signal that their treatment was failing or that death was imminent. Ultimately, the study shows that the success of these conversations is not just about the words used, but about how they are filtered through a patient’s own understanding of their illness and their relationship with their healthcare team.

Keywords

serious illness advance care planning healthcare communication patient experience oncology cardiology

1. Introduction

Serious Illness Conversations (SICs) are structured, clinician-led discussions designed to elicit patients’ values, goals, and preferences in the context of life-limiting illness. When conducted well, such conversations strengthen patient–clinician therapeutic alliance, improve patients’ psychological well-being, and potentially increase the delivery of goal-concordant care.^1–4 Despite growing evidence supporting their benefits, SICs remain underutilised in routine clinical practice.⁵

Barriers to participation in SICs have been well documented and largely parallel those identified for advance care planning. These include prognostic uncertainty, concerns about causing distress, and a lack of patient or caregiver readiness, among others.^6–9 However, most existing studies focus on outcomes of educational interventions and patient perceptions of the Serious Illness Conversation Guide (SICG),^10–13 with few examining how patients and caregivers experience these conversations in real-world clinical contexts. Where patient experiences of SIC are explored, analyses often treat influencing factors as discrete elements, potentially overlooking the complex, interactive effects that these factors have on one another.^3,14,15

Current literature is also predominantly focused on oncology,^1,16–18 leaving the acceptability of SICs in other serious illness contexts relatively under-examined. This represents a significant gap, as the typical cancer trajectory—characterised by a period of relative functional stability followed by a steep decline—contrasts sharply with the erratic, saw-tooth trajectory of heart failure.^19,20 Such variations in disease progression have been shown to shape distinct prognostic understandings and illness experiences, potentially presenting distinct challenges for communication and readiness.^21–23

Recognising that these divergent trajectories may fundamentally alter how patients perceive clinical inquiries, this study investigates the factors and contexts that influence patient and caregiver appraisals of serious illness communication in a real-world outpatient setting, exploring how these factors intersect to shape the participant experiences. Specifically, this study aims to:

1. Compare patient-reported outcomes of SIC acceptability with qualitative narratives to identify points of divergence and contextualise the nuances of participant appraisal;

2. Identify the contextual and dispositional factors that facilitate or hamper SIC acceptability, accounting for variations in disease trajectories, prognostic understandings, and clinical specialties.

2. Methods

2.1. Study design

This study employed a convergent parallel mixed-methods design to integrate quantitative survey data with qualitative interviews. A comparative case-based approach was used to examine the interplay between participant-reported questionnaire data and researcher-coded evaluations of participant experiences using interview data.

2.2. Setting

This exploratory study took place within a six-month implementation of the Serious Illness Care Programme (SICP) across two tertiary medical centres in Singapore—National Cancer Centre Singapore and National Heart Centre Singapore—and recruited individuals with advanced cancer and/or heart failure. This dual-cohort approach was adopted to examine how distinct disease trajectories and illness experiences influence participant experiences of and overall sentiment towards SICs.

2.3. Recruitment

Participants were recruited via clinician referral from a pool of 11 SIC-trained clinicians in the outpatient oncology, cardiology, or palliative care setting at the two study sites. This pool comprised four medical oncologists, two cardiologists, and five palliative care clinicians (two physicians, three nurses).

Patient eligibility criteria included: (i) age ≥ 21 years; (ii) a diagnosis of advanced cancer (Stage III or IV) or symptomatic heart failure (Stage C or D); (iii) clinician-assessed suitability for an SIC, (iv) awareness of diagnosis, and (v) proficiency in English or Mandarin. Individuals with diagnosed or self-declared delirium, cognitive impairment, or poorly controlled mental illness were excluded. Primary family caregivers, excluding domestic helpers or professional caregivers, identified by recruited patients were also invited to participate if they met the age and language requirements. Following a consultation in which an SIC occurred, the first author approached eligible patients and caregivers for study participation.

The recruitment target for this study was initially defined as a provisional range of 25 to 35 participants, an anticipated sample size intended to capture a diverse mix of perspectives across medical oncology, cardiology, and palliative medicine clinics. In line with Braun and Clarke’s guidance on sampling for reflexive thematic analyses, this target was a pragmatic heuristic designed to generate a rich, multi-faceted story about patient and caregiver experiences of SIC.²⁴ During the study, an in-situ decision was made to expand recruitment to 40 participants, as poor health and fatigue associated with advanced illness hindered participation for some.

To ensure the study remained pragmatic and patient-centred, the protocol provided participants with the flexibility to opt out of either the questionnaire or the interview at any stage. Study recruitment took place between 9 December 2024 and 20 February 2025.

2.4. Data collection

Quantitative data were collected using the Patient Experience Survey (PES), a 7-item instrument adapted from the Ariadne Labs Serious Illness Care Programme (S1 Appendix).²⁵ The PES assesses five domains of impact—closeness with clinician, understanding of future health, sense of control, hopefulness, and peacefulness—using a 7-point Likert scale. It also includes a global acceptability item regarding how worthwhile the conversation was perceived to be, as well as an evaluation of how “heard and understood” participants felt. The instrument has been used in previous implementation studies to provide a standardised measure of SIC acceptability.^25–27

Qualitative data were gathered through semi-structured interviews conducted by the first author. The interview guide was developed to systematically elicit participant perspectives across several key domains: general experience with healthcare services received, communication experiences and preferences, participants’ description of the SIC encounter, their immediate reactions to SIC and their retrospective reflections on its role and value (S2 Appendix). This approach ensured that the participants’ experience with the healthcare system was captured as a contextual factor in their appraisal of the SIC. Where caregivers were recruited, interviews were conducted dyadically. Interviews were conducted, audio-recorded, and transcribed by the first author, and reviewed for accuracy by the second.

2.5. Data analysis

Qualitative data were analysed using Braun and Clarke’s reflexive thematic analysis, an iterative process emphasising context-sensitive theme development.^28–30 Each SIC encounter was treated as a unit of analysis. Data from both patients and caregivers were analysed reflexively to identify shared patterns of meaning. Because caregiver accounts largely mirrored and reinforced the themes expressed by patients, separate caregiver-specific themes were not developed. Instead, caregiver insights were integrated into the broader thematic structure to provide a more comprehensive perspective on SIC acceptability.

The first and second authors independently coded the transcripts, moving iteratively between the raw data and emerging themes to identify factors that shaped participant appraisals. The analysis was finalised through collaborative reconciliation of codes to ensure interpretive consonance. Concurrently, quantitative responses from the PES were analysed using descriptive statistics in RStudio (version 2025.05.1).

To facilitate data integration and enable a case-comparative identification of factors influencing SIC acceptability, researchers independently assigned experience ratings (“Good,” “Moderate,” “Poor”) to each SIC encounter. These ratings were based on an evaluation of the participants’ qualitative feedback regarding the encounter. Evaluation criteria were established and tested through a pilot analysis of the first five interview transcripts, during which the authors achieved full consensus. A “Good” rating requires the encounter to be perceived as meaningful, emotionally supportive, or clarifying, characterised by an endorsement of the SIC process and an articulation of values without significant distress. A “Moderate” rating is defined by ambivalence or limited engagement despite an acknowledgment of value, while a “Poor” rating is given where participants indicated significant distress or a prevailing sentiment of dissatisfaction towards the clinician or the SIC encounter.

Following the pilot, remaining transcripts for participants who completed the interview were analysed. Of the 27 interactions analysed, only one discrepancy in researcher-coded experience ratings was noted and this was resolved through discussion (S3 Appendix). To determine if subjective participant narratives aligned with their survey responses and identify points of convergence/divergence, researcher-coded ratings were compared against participant-reported PES results using Kruskal-Wallis rank-sum tests and post-hoc Dunn’s tests with Bonferroni correction.

Coding and data management were conducted using Microsoft Excel. All names used in this manuscript are pseudonyms. A completed Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist may be found in S4 Appendix.³¹

2.6. Ethics approval

This study obtained approval from the institutional review board at the SingHealth Centralised Institutional Review Board (CIRB), reference number: 2024/3019. All participants signed informed consent prior to study participation. This study was conducted in compliance with the Declaration of Helsinki.

3. Results

3.1. Participant characteristics

A total of 40 participants were recruited to the study (33 patients, 7 caregivers), of whom 32 (26 patients, 6 caregivers) completed semi-structured interviews. Reasons for non-participation in interviews included poor health or fatigue (n=6) or the absence of an SIC encounter during the study period (n=2). Among the 26 patients included in this analysis, most lived with advanced cancer (n=19), primarily stage IV, while the remainder had symptomatic heart failure (n=7).

Most in the cohort were evaluated by their primary physicians to be clinically stable (76.9%) at recruitment. The resulting sample reflected a diverse demographic spread across age and ethnicity (Table 1). SICs were initiated by a range of clinicians, including medical oncologists (38.5%), cardiologists (26.9%), palliative care nurses (known as Supportive Care Nurses or SCNs) (19.2%), and palliative physicians (15.4%). Caregiver participants (n=6) were predominantly spouses (83.3%) who provided both physical and emotional support (S5 Appendix).

Table 1.

Characteristics of patient participants included in analysis (n=26).

Characteristic	n (%)
Age group
<40	3 (11.5%)
40 – 59	11 (42.3%)
60 – 69	6 (23.1%)
>70	6 (23.1%)
Sex
Female	13 (50%)
Male	13 (50%)
Ethnicity
Chinese	16 (61.5%)
Malay	4 (15.4%)
Indian	2 (7.7%)
Other	4 (15.4%)
Occupational status
Working full-time	8 (30.8%)
Working part-time	5 (19.2%)
Unemployed	7 (26.9%)
Retired	6 (23.1%)
Primary diagnosis
Cancer	19 (73.1%)
Breast	6 (31.6%)
GI (colorectal, gastric)	6 (31.6%)
Lung	3 (15.8%)
Melanoma and sarcoma	3 (15.8%)
Kidney	1 (5.3%)
Heart failure¹	7 (26.9%)
Disease stage (Cancer)
III	3 (15.8%)
IV	16 (84.2%)
Disease stage (Heart failure)
C	6 (85.7%)
D	1 (14.3%)
Clinician initiating SIC
Medical oncologist	10 (38.5%)
Cardiologist	7 (26.9%)
Palliative physician	4 (15.4%)
Supportive Care Nurse	5 (19.2%)
Clinical trajectory (as assessed by clinician)
Stable	20 (76.9%)
Deteriorating	5 (19.2%)
Improving	1 (3.8%)

¹One participant was diagnosed with both heart failure and cancer. To avoid double counting, the participant is classified as a heart failure patient, as he was first recruited from the cardiologist’s clinic.

3.2. Quantitative results

A total of 25 complete PES questionnaires were collected from 24 patient participants, with one participant completing the questionnaire twice after having separate SICs with his oncologist and cardiologist. Two patients declined to complete the PES due to fatigue.

Survey data indicated high overall acceptability: 96% of patients (n=24) rated the SIC as “mostly” or “extremely” worthwhile. Participants reported net positive impacts across five measured domains, with mean scores clustering around 6 (“increased somewhat”) on a 7-point scale (Table 2). The highest perceived benefit was in closeness with the clinician (mean = 6.41), followed by understanding of future health (mean = 6.06) and sense of control (mean = 5.93). Aggregate impact scores (mean = 29.9 out of 35) indicated that participants perceived the SIC encounter to be beneficial across relational, emotional, and informational domains.

Table 2.

Summary of Patient Experience Survey (PES) results (n=24 patients, 25 responses).

Category	Measure	Result
PES domains	Domain of impact (score out of 7)	Mean (SD)
	Closeness with clinician	6.41 (0.78)
	Understanding of future health	6.06 (1.03)
	Sense of control over medical decisions	5.93 (1.13)
	Hopefulness about quality of life	5.79 (1.18)
	Sense of peacefulness	5.72 (1.16)
	Aggregate score (score out of 35)	29.9 (4.23)
Global acceptability	“Overall, how worthwhile was the conversation?”	n (%)
	Extremely	11 (44%)
	Mostly	13 (52%)
	Somewhat	1 (4%)
	Not at all	0 (0%)
Quality of communication	“Over the past few clinic visits, how much have you felt heard and understood by your clinician?”	n (%)
	Completely	11 (44%)
	Mostly	14 (56%)
	Somewhat	0 (0%)
	Not at all	0 (0%)

3.3. Comparing qualitative ratings and quantitative results

To evaluate the relationship between qualitative narratives and survey data, we compared coder-assigned experience ratings (“Good,” “Moderate,” “Poor”) with PES results. While all patients reported a net positive impact from the SIC, analysis revealed a significant difference in “Heard” scores across experience groups (χ² = 6.147, p = 0.046). Specifically, participants categorised as having a “Poor” experience felt significantly less heard and understood than those in the “Good” group (p=0.021). (See S6 Appendix for detailed results.)

In contrast, “Worthwhile” scores did not differ significantly across categories (χ² = 3.86, p = 0.145), suggesting that the perceived utility of the conversation is independent of the participant’s comfort with the interaction. Even participants who expressed feeling unresolved distress during the conversation retrospectively valued their clinicians’ attempt to initiate it.

This divergence between relatively experience-invariant “Worthwhile” ratings and experience-contingent “Heard” scores suggests that while SICs are generally valued for its intent, its acceptability is also contingent on the quality and experience of patient-clinician communication. To understand the factors behind these varying appraisals, the following qualitative analysis explores the specific factors that shaped participant experiences. Specifically, it examines how these factors contributed to the distress or disorientation noted in “Poor” or “Moderate” SIC experiences, or conversely, how they facilitated the sense of being heard and understood that characterised “Good” experiences.

3.4. Qualitative results

Our thematic analysis of participant interviews revealed four themes, broadly corresponding to four factors—illness experiences, conversational practices, participant disposition, and relational dynamics—that appear to shape participant experiences of SIC. Given the exploratory nature of this qualitative analysis and its focus on interpretive depth rather than statistical representation, these findings offer indicative insights into the complex, non-linear interactions between factors that shape individual expectations and experiences of the SIC encounter. Further, the interactional and context-dependent nature of these themes precludes establishment of causality and does not statistically account for the variance observed in the quantitative scores. Instead, they serve to illuminate the nuanced interplay of factors that informs how participants evaluate their SIC experience.

3.4.1. Theme 1: Subjective illness experiences and disease understandings shaped how participants interpreted and responded to the invitation to engage in SIC

This theme examines how the differing prognostic understandings and clinical norms associated with heart failure and cancer function as interpretive frameworks through which participants appraise the intent and timing of an SIC. These frameworks influenced how participants responded to the invitation to discuss goals, yielding divergent emotional reactions that ranged from a dismissal of the conversation to its interpretation as a loaded signal of clinical decline.

For participants living with heart failure, the condition was typically perceived as a manageable chronic disease rather than a life-limiting serious illness. This perspective was often reinforced by discursive norms within cardiology clinics, with the predominant focus on symptom control, medication optimisation, and preserving disease stability. Within this framework, some participants like Abdul and his spouse, Roshana, questioned if the former’s condition was ‘severe enough’ to merit a goals-of-care conversation. This disconnect was exemplified by Roshana’s repeated observation that her spouse had “never been pushed into ICU [intensive care unit] or high-dependency ward.” For the couple, the lack of a critical medical event rendered the discussion of goals and priorities premature and at odds with the prevailing clinical goal of health maintenance.

In contrast, cancer was widely viewed through a cultural imaginary as a “death sentence.” Because the diagnosis was already freighted with associations of mortality, SIC initiation was frequently interpreted as a tacit signal of treatment failure or disease progression, triggering anxiety and distress in several participants. Despite being in remission and reassurances from her oncologist that her scans revealed no recurrence, Cindy highlighted that the conversation evoked fears that she struggled to suppress:

“Actually, I felt uncomfortable hearing that, because to hear these words suddenly… because we are already fearful. In the beginning, when I learnt about this, I am already feeling very scared, very scared.” (Cindy, 70s, in remission from locally advanced breast cancer)

Whereas the conversation often felt premature or irrelevant for individuals with heart failure, SIC initiation was perceived to imply impending decline by those with cancer. Anxieties were particularly heightened in those conversations where future priorities and extent-of-care questions were raised abruptly. The difference may be attributed to the discursive effects of routines in clinical care and communication: medication optimisation in the management of heart failure was variably described as means of “recovery” and “getting stronger,” but cancer treatment was more commonly understood—especially among those with metastatic disease—as being at risk or even on the cusp of failure.

Beliefs regarding the purpose of SIC initiation thus appeared to be significantly influenced by disease-specific illness experiences and prognostic understandings. For heart failure patients, a focus on health improvement and the perception of the condition as a manageable chronic illness often fostered a view of the SIC as irrelevant or personally meaningless. Conversely, the experience of living with advanced cancer was frequently defined by the shadow of terminality, transforming the invitation to SIC into ‘excessively meaningful’ communicative gesture that conveyed imminent deterioration irrespective of the participants’ clinical condition and despite their clinicians’ assurances of disease stability.

3.4.2. Theme 2: Conversational practices shaped the relational tenor of SICs and the subjective experiences of being heard

The qualitative data suggest that variations in how “heard and understood” participants felt were primarily determined by how clinicians facilitated the conversation rather than the specific content covered. This theme illustrates how certain conversational practices modulated the relational tenor of the encounter and influenced participant appraisals. While most participants retrospectively affirmed the utility of SIC, the extent to which they felt heard appeared to depend on the clinician’s ability to move beyond a task-oriented framework toward an embodiment of genuine concern and person-centred engagement.

Differences in participant experiences were necessarily tied to disease type but were nonetheless associated with the structural routines and time constraints differently experienced by clinical disciplines. In outpatient oncology and cardiology settings—characterised by high-volume caseloads and consultations structured around the review of lab results and treatment progress—SICs were often experienced as abrupt and disorienting interruptions to the established clinical flow. For instance, Ahmet, a young patient with a Left Ventricular Assist Device (LVAD), described his cardiologist shifting “all of a sudden” from a discussion on weight loss and transplant eligibility to an inquiry into his life priorities. Absent a clear clinical rationale for this transition, Ahmet struggled to discern his clinician’s intent, ultimately leading him to disregard the SIC and focus instead on “adjusting (his) health, mentally and physically.” This suggests that when the SIC is perceived as an afterthought to the routines of clinical communication, it risks being interpreted as superfluous.

In contrast, the most positive appraisals—predominantly observed in palliative care encounters, where seven out of nine encounters were rated as “Good”—were characterised by a seamless integration of SIC questions into clinical communication. For these participants, questions about values and preferences were an ordinary, if not unremarkable, extension of routine care. Osman, for instance, perceived his palliative care physician’s questions about his priorities to be “like normal,” viewing them as evidence of a sincere interest in his “life and medication and all those stuff,” a regard for his wellbeing that dissolved the distinction between medical and personal concerns. This integration facilitated a relational tenor that validated the participant’s broader identity beyond their clinical diagnosis.

The analysis further identified conversational practices that undermined the perceived relational authenticity of the encounter. Participants like Annette noted a sense of dissatisfaction when their clinicians were seen referring to the Serious Illness Conversation Guide or introduced the conversation as part of a specific “project” for which they seek their help in completing. For Annette, the visible presence of the Guide transformed what she had hoped would be an “intimate and sensitive discussion” into an impersonal, performative gesture. Her reflection highlights a tension between the standardisation of communication tools and the relational depth participants seek:

“I was under the illusion that the palliative care session would be an intimate and sensitive discussion. But seeing the conversation guide, it felt like seeking a spiritual counsellor, only to find out that everything she said was scripted.” (Annette, 40s, living with advanced melanoma)

For others, the experience of being heard was undermined by conversational practices that prioritised prognostic disclosure over participant readiness or autonomy. While information regarding the future was often rationalised by participants as a sign of clinical concern—potentially supporting the high “Worthwhile” scores observed in the PES results—the involuntary nature of certain disclosures left participants feeling disempowered. For example, despite her participation in the dialogue, Sarah felt she had “no choice” but to receive information she had actively avoided:

“I don’t want (my oncologist) to tell me, because when you know, you will keep thinking… all the while for so long, I never never asked the doctor [oncologist] before! But it’s ok. (Oncologist) also cannot don’t let me know, right? They are all okay.” (Sarah, 50s, living with lung cancer)

This dynamic suggest that while the presumed intent of the conversation is valued, the execution can inadvertently diminish a patient’s sense of agency, possibly contributing to the lower “Heard” scores reported for these patients.

Ultimately, the acceptability and experience of SIC encounters appear to shaped by the relational tenor of communication. When conversational practices were perceived to be adapted to the participant’s emotional rhythms and integrated into the ordinary flows of care, the dialogue was consistently appraised as therapeutic. Conversely, when the SIC was perceived as an extraneous task or completed with haste, it was more likely to evoke ambivalence or dissatisfaction. These findings suggest that the relational quality of facilitation is a key contributing factor of the experience of being heard, advancing a possible mechanism and explanation for the variations in SIC experiences.

3.4.3. Theme 3: Participant appraisals of SIC acceptability were modulated by individual histories with mortality and subjective readiness to engage with prognostic futures

While Theme 1 identifies how illness experiences and prognostic beliefs shaped interpretations of SIC encounters, qualitative data suggest that individual appraisals of the SIC experience were further modulated by personal dispositional factors that shape their readiness to confront prognostic uncertainties, mortality, and future care needs. Notably, these dispositional factors appeared independent of clinical diagnosis, with neither heart failure nor cancer patients exhibiting a uniform response.

For many participants, regardless of their specific illness, the clinician’s attempt to explore goals of care was perceived as a disturbance to the psychological equilibrium they maintained through the avoidance of terminal realities. Faris, living with cancer, expressed feeling distressed at what he perceived as his clinician’s morbid preoccupation with death:

“I don’t know why he like to tell me about die… I also don’t want to think.” (Faris, 50s, living with sarcoma)

Similarly, Jean, a heart failure patient, was shaken by her cardiologist’s questions about acceptable life-saving measures, later reflecting,

“Is it the end of the world? After that, the whole day, I was thinking… Although this question is a… how to say, it’s a fact question, but it’s just that I try not to think (about) it.” (Jean, 30s, living with symptomatic heart failure)

These instances indicate that when a participant’s primary psychological strategy involves preserving a sense of normalcy through avoidance, the invitation to discuss one’s goals and priorities may be appraised as an existential threat and an unwelcome confrontation.

Conversely, receptiveness to SIC was often facilitated by prior vicarious or direct exposure to death and suffering of others. For these participants, the conversation did not arouse new anxieties but appeared to provide a platform for articulating pre-existing goals and concerns. Lilian, for instance, drew on her experience witnessing the prolonged suffering of a friend to articulate her preference for avoiding life-prolonging measures:

“I feel that she’s suffering a lot of pain. So I say that, if I must go through that stage, I cannot go out, show my beauty-ness, I cannot work out, I must sit on the sick-bed, then I rather don’t want (to prolong my life).” (Lilian, 50s, living with metastatic breast cancer)

For these participants, SIC was welcomed as a means of ensuring that their own death would not mirror the upsetting trajectories they had observed in others.

The analysis suggests that the SIC encounter functions as a catalyst that interacts with a participant’s existing dispositional readiness. While the initiation of these conversations evoked anxiety in several cancer patients and dismissiveness in those with heart failure (Theme 1), these reactions were not universal or consistent along the lines of disease type or severity. Rather, the encounter appears to either surface or validate pre-existing values (as seen in Lilian’s experience) or to disrupt the protective avoidant stances participants used to cope with their illness (as evidenced by Faris and Jean). Therefore, the acceptability of the SIC is deeply rooted in personal history and the subjective proximity to death, underscoring the need for clinician sensitivity to individual affective readiness.

3.4.4. Theme 4: Established trust functioned as a buffer that sustained the perceived utility of SICs despite evocative distress

The final theme identifies trust and rapport as interpretive filters that modulate how participants appraised the clinical intent of the SIC. By distinguishing between longitudinally established trust and generative rapport constructed during the encounter, the following analysis examines how pre-existing bonds helped certain participants tolerate distressing inquiries. At the same time, for some participants, the absence of a prior relationship can be mitigated by emotionally sensitive facilitation.

For most participants seen by their oncologists or cardiologists, the SIC encounter was situated within a long-term therapeutic relationship. In these instances, participants across both cohorts re-evaluated potentially distressing inquiries through the lens of their ongoing relationships. Just as Sarah accepted that her oncologist “cannot don’t let (her) know” her prognosis, Yikai rationalised that it was “normal” and thus understandable for his oncologist to wish to seek his thoughts on his extent-of-care preferences, a belief that mitigated the initial shock evoked by his doctor’s questions. Irshad, a participant living with both cancer and heart failure, described a sense of familial closeness with his oncologist by virtue of having been under his care for many years, despite not always fully understanding him due to language barriers. Reflecting on his joy at seeing his oncologist, Irshad likened the SIC encounter to a conversation with a “friend”:

“I don’t know, I see the face only, then I happy, ‘Oh, reach my doctor already.’ … (He’s) a friend, like a family member… (Talking to him,) I feel free, like happier.” (Irshad, 60s, living with gastric cancer)

Similarly, Christine, a heart failure patient, interpreted her cardiologist’s shift towards personal values as a refreshing development in their therapeutic relationship. For her, the clinician’s departure from the “medical side” was interpreted as a “new approach” that validated her personhood and an effort to help patients “know that they’re living for something”:

“Usually, he will talk more of the medical side. So (it’s the) first time for him to ask about our personal (lives) – the patient’s personal views and all that… I can say, ‘Eh, Doctor is different today!’” (Christine, 30s, living with advanced heart failure)

In these cases, established trust functioned as a relational buffer, allowing participants to read difficult questions as gestures of concern.

Conversely, in encounters with Supportive Care Nurses (SCNs), with whom participants typically had no prior history, trust and rapport were generative outcomes of the SIC. Shakshi, a cancer patient, interpreted the invitation to an SIC as a demonstration of the nurse’s professionalism, noting that the nurse went the “extra mile” to understand his personal values and goals:

“I mean she [SCN] doesn't know me at all, personally or otherwise. So for her to take the time and the trouble, I thought it was a very nice gesture… I wasn't even expecting that call, to be honest, so that shows that in your organisation, there are people who are going the extra mile.” (Shakshi, 60s, living with colon cancer)

This rapid formation of a relational bond in the span of a single conversation suggests that the experience of being heard may be a direct product of the clinician’s facilitation skills, recalling Theme 2 of this analysis. Marianne, likewise a cancer patient, observed that her rapport with the SCN was built “little by little” through the conversation:

“Little by little, she got to know me, and I got to know her little by little. And so that day when she called me to ask further, more in-depth questions, then I was not averse to any of her probing.” (Marianne, 70s, living with colon cancer)

These examples suggest that while a prior relationship is not a necessary precondition for an effective SIC, its absence may be compensated for with sufficient interactional sensitivity and effective facilitation skills to contribute to a positive SIC experience.

These findings offer a provisional explanation for the relative stability of “Worthwhile” scores observed in the quantitative results: participant evaluations of the utility of SIC were refracted through the lens of relational maintenance, wherein established trust allowed participants to affirm the encounter’s value despite the distress it may have evoked. As illustrated by the accounts of Yikai, Faris, and Jean, participants frequently attributed clinical rationales to their clinicians and accepted the relevance of exploring goals of care, even when such rationales remained opaque to them. Yikai’s reflection typifies this shift from initial shock to retrospective rationalisation:

“Because he said that the blood test is normal. That’s why when he mentioned this [extent-of-care question], I was a bit shocked. I thought, ‘Eh, why would he ask this?’ After that, I think it’s normal for him to ask this.” (Yikai, 70s, living with metastatic kidney cancer”

Conversely, the consistently positive appraisals of encounters led by supportive care nurses suggest that the confluence of effective facilitation (Theme 2) and personal readiness (Theme 3) may generate sufficient relational safety to overcome the absence of a longitudinal bond. In these instances, the clinician’s interactional sensitivity and the participant’s own openness appeared to function as a generative substitute for a pre-existing relationship, fostering favourable appraisals of the encounter as beneficial, worthwhile, and emotionally supportive.

However, it is important to acknowledge that the current dataset lacks a negative test case—specifically, an encounter characterised by both the lack of a prior relationship and poor facilitation—to problematise the hypothesis tentatively posited above. Because participants who engaged with SCNs reported universally positive experiences, the absence of a “Poor” encounter within this novel relational context precludes an assessment of whether the perceived utility of the SIC can persist in the absence of both established trust and effective facilitation.

4. Discussion

While survey responses suggested that most participants found their SIC experience acceptable, echoing findings from other SICP initiatives,^1,3,14,32 our qualitative findings revealed a more nuanced picture of ambivalence, anxiety, and retrospective rationalisation. This discrepancy may be explained with reference to the participants’ subjective illness understandings (Theme 1), the clinicians’ conversational practices (Theme 2), the participants’ varying degrees of affective readiness (Theme 3), and the modulating influence of the participant-clinician relationship (Theme 4).

One noteworthy finding in this study is the divergence between “Heard” and “Worthwhile” scores across experience categories. While participants who reported a “Good” experience felt more heard and understood, “Worthwhile” scores remained relatively high even among those who experienced the encounter as distressing or irrelevant. Our qualitative data suggests that longitudinally established trust (Theme 4) functioned as a relational buffer, with some participants retrospectively attributing benevolent intent to their clinicians to justify SIC initiation. In these instances, the perceived utility of the SIC may be traced to a ‘relational maintenance’ process where participants conceived of the inquiry as a necessary, albeit unsettling, aspect of their care.

Our analysis of factors influencing SIC acceptability carries significant implications for clinical practice, particularly regarding the timing and pacing of SIC initiation. While positive appraisals of SCNs’ SIC facilitation (Theme 4) demonstrates that rapport can be built within a single session, the findings across Themes 1-3 suggest that readiness for such explorations may take time to develop. For participants who perceive their condition as a manageable chronic illness—a perspective articulated by several heart failure patients—the abrupt initiation of an SIC was observed to elicit unease and disorientation (Theme 1). Given that clinic proceedings in cardiology and oncology tended to be structured around clinical review, an unanticipated pivot to eliciting participants’ views on their values, goals, and priorities contributed to considerable anxiety (Theme 2), particularly among those preferring to cope with the stressors of living with serious illness by avoiding illness-related thoughts (Theme 3).

Clinical practice may thus benefit from a ‘graduated initiation’ model in which goals-of-care exploration is initiated first as a series of lower-stakes inquiries into daily activities, social support, and everyday coping, before exploring the goals and priorities patients have. Such an approach respects the high threshold for ‘seriousness’ identified in our findings and provides a pathway for normalising values-based dialogue before confronting more distressing prognostic realities.^9,33 This approach also allows clinicians to better understand the patients’ coping styles and informational preferences, and thus be better equipped in approaching these discussions with tact and sensitivity.³⁴

At the same time, however, our analysis clarifies that trust and rapport need not be accrued over years prior to SIC initiation. Rather, as indicated by our findings regarding SCNs in Theme 4, rapport can be actively generated and rapidly developed when clinicians employ emotionally sensitive, personhood-affirming conversational practices (Theme 2). This observation aligns with a meta-ethnographic synthesis that identified communication with authenticity and transparency, gaining insight into the patient’s lifeworld, providing professional support, and maintaining therapeutic boundaries as active ingredients to rapport-building.³⁵ However, it diverges from the findings in the literature that characterise rapport formation as a gradual process requiring repeat and consistent engagement.^35,36 While there appears to be no study to date systematically examining the feasibility of establishing sufficient connection for goals-of-care exploration within a single therapeutic encounter, this study provides preliminary evidence for its viability. Further research is required to isolate the specific interactional mechanisms that facilitate such rapid rapport-building in the context of serious illness care.

This study’s primary strength lies in its mixed-method design, integrating interviews and survey data to provide a context-rich understanding of patients’ experiences of SICs. The triangulation proved useful in reconciling the positive survey results with the complexities of participants’ qualitative evaluation of their SIC experiences. Further, by employing a comparative case approach, we identified how interactional patterns varied across specialties and between participant-clinician interactions, lending depth to our qualitative findings. Finally, conducting this study in a real-world clinical context ensured that the findings best approximate serious illness care experiences.

This study faced several limitations that necessitate a cautious interpretation of its findings. Selection bias may have skewed findings towards more favourable appraisals, as patients with negative encounters were more likely to decline participation. Moreover, while the PES facilitates inter-study comparisons, it lacks direct emotional measures and may be subject to ceiling effects. This limitation is likely exacerbated by social desirability bias, where relational loyalty prompts favourable ratings that obscure the nuanced discomfort revealed in qualitative interviews. Within our mixed-methods framework, however, this discrepancy functioned as a productive analytical tool to understand how participants rationalised distressing encounters as “Worthwhile” discussions. Nonetheless, future iterations of the PES should incorporate more sensitive measures of affective impact to better capture these complex internal states.

In addition, the sample was weighted towards oncology patients (n=19/26) and clinically stable participants (n=20). This imbalance resulted primarily from the mid-study withdrawal of a participating oncologist, which impeded recruitment in the heart failure cohort, rendering our findings—especially those concerning the cardiology setting—preliminary. At the same time, this study recruited a small number of caregivers. While caregiver recruitment enabled dyadic triangulation in specific cases, it precluded a dedicated comparative analysis of caregiver-specific needs. However, the high degree of consonance between patient and caregiver accounts suggests that the identified themes accurately reflect the shared emotional and interpretive landscape of the family unit. Finally, as this study employed a reflexive thematic analysis approach focused on generating interpretive depth rather than achieving statistical power, no formal sample size calculation was performed. While the final recruitment of 40 participants was intended to buffer against the high attrition rates common in seriously ill cohorts, the modest final sample of completed surveys (n=25) indicates that quantitative findings remain exploratory.

5. Conclusion

This study demonstrated that the acceptability of serious illness conversations is dynamically influenced by factors across multiple domains. While quantitative surveys indicate positive appraisals, qualitative findings revealed that participant experiences and evaluations of the SIC encounter were refracted through interpretive lenses of subjective illness understandings and, for most, established relational dynamics. Our exploratory analysis of the complexities of serious illness communication offers insights into how clinicians can facilitate values-based discussions more effectively to strengthen therapeutic alliance with patients and deliver better care experiences.

Supplemental material

Supplemental material - What makes serious illness conversations acceptable? A mixed-methods study of patient and caregiver experiences in oncology and cardiology

Supplemental material for What makes serious illness conversations acceptable? A mixed-methods study of patient and caregiver experiences in oncology and cardiology by Alston Ng, Su-Min Yeo, Shirlyn Hui-Shan Neo in Palliative Care and Social Practice

Supplemental material

Supplemental material - What makes serious illness conversations acceptable? A mixed-methods study of patient and caregiver experiences in oncology and cardiology

Supplemental material

Supplemental material - What makes serious illness conversations acceptable? A mixed-methods study of patient and caregiver experiences in oncology and cardiology

Supplemental material

Supplemental material - What makes serious illness conversations acceptable? A mixed-methods study of patient and caregiver experiences in oncology and cardiology

Supplemental material

Supplemental material - What makes serious illness conversations acceptable? A mixed-methods study of patient and caregiver experiences in oncology and cardiology

Supplemental material

Supplemental material - What makes serious illness conversations acceptable? A mixed-methods study of patient and caregiver experiences in oncology and cardiology

Footnotes

Acknowledgements

The study team extends its thanks to the Lien Centre for Palliative Care and its clinician partners for supporting the implementation of the Serious Illness Care Programme at National Cancer Centre Singapore (NCCS) and National Heart Centre Singapore (NHCS).

ORCID iDs

Alston Ng

Shirlyn Hui-Shan Neo

Ethical considerations

This study obtained approval from the institutional review board at the SingHealth Centralised Institutional Review Board (CIRB), reference number: 2024-3019.

Consent to participate

All participants signed informed consent prior to study participation. This study was conducted in compliance with the Declaration of Helsinki.

Author contributions

AN: Formal analysis, Investigation, Data curation, Writing – Original draft preparation, Writing – Review & Editing; YS: Formal analysis, Writing – Review & Editing; SN: Writing – Review & Editing, Supervision, Funding Acquisition. All authors have made substantial contributions to the work, have critically revised and approved the final manuscript, and agree to be accountable for the content of the work.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by National Medical Research Council (NMRC) Research Training Fellowship (RTF) seed fund, ref: SEEDFD23jul-003.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.*

Supplemental material

Supplemental material for this article is available online.

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