General discussion 191 concordant with the patient and family’s needs and wishes. They can timely prepare for the end of life. In scientific literature, proactive palliative care is often equated to early palliative care, and involves timely identification of patients with palliative care needs, proactive conversations about patients’ and family’s wishes about the end of life, patient empowerment and prevention of future problems.11, 12 However, proactive palliative care not only refers to early palliative care, but is an appropriate approach along the whole illness trajectory. Sometimes, dependent on the illness trajectory, it is not possible to initiate palliative care early; in these cases, a ‘late’ proactive approach is also demanded to achieve person-centred and appropriate care. Proactive palliative care includes actions such as goals-of-care discussions, multidimensional treatment of symptoms and supportive care of patient and family, multidisciplinary collaboration, and preventive medicine. Other aspects of proactive palliative care are communication with other healthcare providers about end-of-life issues and making and sharing proactive care plans.13-18 Palliative care can therefore be considered as an active approach to care in the last phase of life with proactive characteristics. The 2017 Netherlands Quality Framework for Palliative Care indeed describes that one of the core values of palliative care is being proactive: “Together with the patient and family, the physical, psychological, social and spiritual dimensions should be proactively assessed and documented for situations in which: • normal, everyday attention is enough; • there is a need for guidance or treatment; • crisis intervention is necessary.”19, 20 In proactive palliative care, goals of care should be discussed in shared decision-making. Aligning with the 2002 World Health Organisation’s definition of palliative care and the previously derived definition of proactivity, proactive palliative care has the following goals:3, 21 • to produce a good result, i.e., to improve or maintain quality of life and appropriate care.22 Appropriate care is associated with good supportive care, care decisions including waiving or stopping treatment, sufficient symptom relief, care at home, following wishes of the patient, and effective communication (including advance care planning, right attitude, listening and informing).23 To achieve this, palliative care should be of good quality and in line with preferences of patients and family, while taking into account the four dimensions of palliative care (psychological, social, physical and spiritual), and stimulate self-management of patients and family. To optimally benefit from palliative care, a palliative care approach should be integrated into standard care early in the disease trajectory. Along the whole illness trajectory, 8
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