Chapter 8 198 The two-track approach in Chapter 4 suggests a continuous evaluation of the goals of care. The cues for proactive care that were collected in Chapters 3 and 4 can also be used for reviewing if the care delivered is concordant with the wishes of patients and family: • Documentation of communication about the condition of the patient between a hospital clinician or palliative care specialist and the general practitioner of the patient. This communication could have occurred via a letter, telephone call or transfer notes. • Documentation of proactive care plans, which could be the following documents: o Care plans for anticipating future symptoms or worsening symptoms; o Care plans directed at informing the general practitioner; o Care plans written by the palliative care consultation team; o Referrals to the palliative care consultation team. • Documentation of limitations on life-sustaining treatments (i.e., no resuscitation, no ventilation, no admission to the intensive care unit). In summary, commonly used indicators for quality of end-of-life cancer care may not be applicable for patients with a haematological malignancy and do not explain what quality proactive palliative care entails. Goal concordance, which is part of the twotrack approach, can be an indicator of proactive palliative care and can be found in documentation in patient records. 2. Timely identification of palliative care needs: ED-triggered palliative care in patients with advanced cancer In order to produce good results and avoid (future) problems (for definition, see 8.3.1), patients with palliative care needs should be timely identified. Early identification of palliative care needs can be difficult. Patients use acute healthcare resources more often in the last phase of life. Reasons for admission to an Emergency Department (ED) or hospital ward include serious symptom burden, not being able to manage at home, caregiver burden or lacking resources in the community setting.59-62 Reaching out for acute medical help in the last phase of life may indicate disease progression and urgent palliative care needs. Because of this, events such as hospitalisations and EDvisits can function as triggers to consider if the patient can benefit from a palliative care approach.63-67 Chapter 3 illustrates that ED-visits triggered initiation of discussions on and documentation of limitations on life-sustaining treatments in many of the patients visiting the ED. This thesis addresses two elements of ED-triggered palliative care for patients with advanced cancer: identification of patients with urgent palliative care needs; and estimation of the urgency of palliative care needs using the Surprise Question and poor physical performance. In Chapter 3, risk factors for approaching death were identified to support identification of patients with advanced cancer visiting the ED: a diagnosis of lung cancer, neurologic deterioration, dyspnoea, hypercalcaemia, and jaundice. Together with triggers for
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