General discussion 185 This chapter consists of five parts. Part 1 provides the main findings of the studies presented in this thesis. Part 2 reflects on the methodologies used in our studies. Part 3 describes the implications of the outcomes of this thesis regarding a proactive approach in palliative care. Part 4 includes recommendations for future research and Part 5 provides recommendations for education, clinical practice, and policy. 8.1 MAIN FINDINGS Objective 1: To assess the extent to which end-of-life care is taught at medical schools in the Netherlands and to find opportunities to improve Dutch medical curricula. Chapter 2 describes a cross-sectional study assessing the extent to which end-of-life care was part of Dutch medical curricula. This study was focused on end-of-life care as essential part of palliative care. The study was conducted during the academic year of 2015-2016. A checklist including the essential domains of end-of-life care education was constructed based on literature. The study demonstrated that the national blueprint on medical education included four of the five domains of end-of-life care. One faculty taught an elective course that included all essential domains. None of the eight medical faculties taught all domains of end-of-life care; these domains were taught in the light of other courses but did not specifically address end-of-life care. Objective 2: To explore palliative care needs and the extent of proactive care in patients with advanced cancer who visited the emergency department (ED) in the last three months of their lives. Knowledge about problems leading to visits to the Emergency Department (ED) in patients in the last three months of their lives and about who are at high risk of approaching death is relevant in ED-triggered palliative care. In Chapter 3, we conducted a mortality followback study in 420 patients with advanced cancer who visited the ED up to three months before they died. Our study showed that their care was often still focused on diseasemodification. Only a few patients had limitations on life-sustaining treatments. This may have led to a high percentage of hospitalisations and in-hospital deaths in this study. Factors associated with approaching death were lung cancer, neurologic deterioration, dyspnoea, hypercalcemia, and jaundice. 8
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