Chapter 1 12 1.1 Early integration of palliative care Accumulating evidence shows that a palliative care approach can improve the quality of life of patients and their families. In 2016, Kavalieratos et al. published a systematic review and meta-analysis including 43 randomised controlled trials on the association between palliative care and outcomes of patients and their family. They demonstrated that palliative care improves patients’ quality of life, which was clinically significant after one and three months of follow up. Other effects of palliative care include reduced symptom burden, more occurrence of advance care planning, improved patient and care giver satisfaction, and less use of healthcare resources.8 Several randomised controlled trials have shown the benefits of early integration of palliative care into standard care. A Cochrane review from 2017 on the effect of early palliative care provided by specialised palliative care teams for adults with advanced cancer demonstrated that early palliative care improved health-related quality of life and reduced symptom intensity.9 A more recent Belgian randomised controlled trial showed that systemic integration of palliative care into oncologic care versus standard oncologic care improved quality of life after twelve weeks in patients with cancer with a life expectancy of twelve months.10 Patients who received early palliative care reported a better quality of life six months and one month before they died, compared to patients who received standard care.11 1.2 The quality of end-of-life care Early integrated palliative care should be available for each patient because it can prevent sub-optimal and inappropriate care. De Schreye et al. defined inappropriate care as ‘treatment and/or medication in which the expected health benefit (e.g., increased life expectancy, improved functional capacity) does not exceed the expected negative consequences (e.g., morbidity, anxiety, pain) by a sufficiently wide margin that the procedure is worth doing, exclusive of cost.’12 Earle et al. formulated quality indicators for studying end-of-life care in cancer patients.13 Their four major categories of poor-quality end-of-life care are: • initiation of a new anti-tumour regimen or continuing current treatment until near death; • recurrent visits to the emergency department, hospitalisations, admissions to the intensive care unit near death; • no or late enrolment in hospice care; • death in an acute hospital setting. The use of healthcare resources increases in the last phase of life. A study on healthcare utilisation in the last month of life by all Dutch patients who died of or with cancer in 2017, showed that palliative care provided by clinicians not specialised in palliative care was
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