General introduction 13 registered in 39% in the last year before death. This study further demonstrated that 34% of patients received potentially inappropriate end-of-life care in the last month of life according to Earle’s quality indicators: 5% received chemotherapy, 6% were admitted to the intensive care unit, 8% spent more than fourteen days in-hospital, 9% were hospitalised twice or more often, 12% had visited the emergency department more than once and 20% died inhospital. Potentially inappropriate end-of-life care occurred five times less in patients who received palliative care at least thirty days before death.14, 15 A study on medication use in the last days of life in the Netherlands reported that 27% of the patients still were prescribed preventative medication on the day they died.16 Another Dutch study found that clinicians order less diagnostic procedures and prescribe less preventive medication in the last 72 and 24 hours before the patient dies if they are aware of the patient’s impending death.17 Randomised controlled trials conclude that integration of specialist palliative care can prevent inappropriate care at the end of life. Temel’s landmark study from 2010, in which 151 patients with metastatic non-small-cell lung cancer were randomised to palliative care plus standard oncological care or standard care alone, showed that in patients receiving palliative care, end-of-life care was less aggressive according to Earle’s quality indicators.18, 19 Maltoni et al.’s randomised controlled trial reported that 107 patients with advanced pancreatic cancer who received palliative care (versus standard oncologic care, n=100) were admitted to a hospice more often, were in hospice care for a longer period and underwent chemotherapy less often in the last thirty days of life.20 2. PALLIATIVE CARE IN THE NETHERLANDS 2.1 The generalist plus specialist palliative care model In the Netherlands, 32% of the patients die at home and 25% die in the hospital.5, 21 Many healthcare professionals provide care to patients who are in the last phase of life and their family. It is warranted that all healthcare professionals working with vulnerable patients are aware of the benefits of palliative care integrated into standard care for quality of life and prevention of inappropriate end-of-life care. Also, they should know their own role in providing such care. To improve palliative care provision among all healthcare professionals, palliative care in the Netherlands is organised in line with Quill and Abernethy’s concept of generalist (or: primary) palliative care plus specialist palliative care.22 Healthcare professionals providing generalist palliative care are those who have basic knowledge and skills in providing palliative care. This includes basic management of pain and other symptoms; basic management of depression and anxiety; and basic ability to have conversations about prognosis, goals of treatment, suffering and code status. Specialist palliative care is the responsibility of clinicians specialised in palliative care. They manage refractory pain or other symptoms; manage more complex depression, anxiety, 1
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