General introduction 15 working in palliative care were formulated in the COMPARE! Project, which was finished in 2013.4, 36 A Dutch study among nurses demonstrated that 75% felt they need more education about subjects related to care for the dying. Subjects they most needed education on were knowledge of dying in other cultures; juridical aspects of euthanasia and assisted suicide; palliative sedation; providing support in coping with approaching death or saying goodbye; and decision-making at the end of life.37 Knowledge and skills regarding palliative care of Dutch medical doctors had not been assessed in detail yet. A study from 2009 showed that 30% of Dutch medical doctors have insufficient knowledge about pain treatment.4 Medical doctors often consult a colleague or pharmacist for complex cases of pain; 40% reported never having consulted a palliative care consultation team. Additional education about the use of opioids, pain treatment and palliative sedation was appreciated by 83% of the medical doctors in this study.38 The Palliantie programme characterised palliative care education as one of three main pillars in improving palliative care.26 IKNL indicated that palliative care generalists lack knowledge and skills regarding palliative care. Barriers to providing quality palliative care were, amongst others, that healthcare professionals did not identify the palliative phase, did not perform advance care planning, and had limited expertise in generalist palliative care.39 Generalist healthcare professionals should be educated in how to identify patients with palliative care needs. Using criteria for referral to specialist palliative care, or using tools such as the Surprise Question, can help to timely identify patients with palliative care needs.40 3. IDENTIFICATION OF PATIENTS WITH PALLIATIVE CARE NEEDS Early identification of patients who may benefit from a palliative care approach is essential in achieving better quality of life.41 There are several approaches that are helpful to identify patients with possible palliative care needs: • Recognition of illness trajectories in palliative care (see 3.1) • Recognition of trigger moments (see 3.2) • Estimation of the patient ’s functioning and other clinical characteristics (see 3.3) • Estimation of life expectancy (see 3.4) • Use of the Surprise Question (see 3.5) • Use of tools combining identification methods (see 3.6) 3.1 Recognition of illness trajectories in palliative care Murray et al. described trajectories of functional decline of three main illness categories (Fig. 1).42 In trajectories of incurable cancer, patient functioning remains fairly stable for weeks to years until a steep decline occurs in the last phase of life. During the stable phase, palliative care can prepare patients and their family for the last phase of life. The second 1
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