Surprise Question and performance status indicate urgency of palliative care needs 103 longest survival in our study, their median survival was only nine months, indicating that they were likely to already have had palliative care needs before the ED-visit. Therefore, for all patients with advanced cancer, we recommend a two-track approach in which disease-modifying treatment is complemented with palliative care and conversations about patient ’s wishes to prepare for the last phase of life.44 Secondly, NS-patients were characterized by a poor performance status with multiple symptoms and a median survival of three months. In these patients, palliative care directed to symptommanagement and quality of life should be discussed as soon as possible. Thirdly, NSpatients with ECOG 3-4 had the shortest median survival of only 1 month, indicating that they are in the end-of-life phase. Therefore, in NS plus ECOG 3-4 patients, end-of-life care according to patient ’s wishes should be initiated immediately. In our study, it seems that physicians at the ED were able to mark deterioration and futility of treatment in the most vulnerable patients. In 16% of the patients without documented limitations on life-sustaining treatments (LSTs) before the ED-visit, limitations on lifesustaining treatments were documented afterwards. This phenomenon is known as ED-initiated palliative care, in which ED-visits function as ’trigger‘ to evaluate a patient ’s health status and situation.6 Interestingly, all patients in whom LSTs were discussed after the ED-visit were NS-patients, demonstrating that LST-documentation in our hospital was focused on those with the shortest life-expectancy. However, S-patients had a limited survival as well, which means that all patients with advanced cancer can benefit from ED-initiated palliative care. Strengths and limitations This prospective study with a long follow-up until February 2019 evaluates the prognostic value of the one-year SQ in patients with advanced cancer visiting the ED. Recall bias of attending physicians answering the SQ and assessing ECOG performance status is possible because e-questionnaires were sent within one working day. After this time period, physicians might regard their patients differently, with possible bias that sicker patients were remembered more likely than those not as sick. As patient and disease characteristics were abstracted from EPRs, under- or over-registration of symptoms is possible; also, physicians might have individual preferences for documenting the main symptom. Since symptoms of the four domains of palliative care are not systematically registered at the ED, this is especially true for psychological, social, and spiritual symptoms. We chose to study the association between indicators of palliative care needs with approaching death rather than with death <1 year, because predictors for approaching death indicate which patients need palliative care most urgently. 5
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