General discussion 199 palliative care derived from previous literature, these risk factors were integrated into a risk assessment tool.68 The use of these triggers can support ED-clinicians in choosing actions leading to appropriate care for vulnerable patients. These actions include goalsof-care discussions, assessment of patients and family needs, referral to the preferred place with appropriate care and referral to specialist palliative care for complex problems. Although risk assessment tools for approaching death can be useful in the ED-setting to organise appropriate care,69-71 they are not suited for early identification of patients with palliative care needs. The study in Chapter 5 demonstrated that the surprise question was a predictor for death within one year with a high sensitivity and positive predictive value, and can be used as a screening tool to early identify patients with palliative care needs in patients with advanced cancer visiting the ED. Specificity and c-statistic improve if poor functional status (ECOG 3 or 4) is added as a second step following the surprise question. A similar effect has been demonstrated in a study in elderly visiting the ED demonstrated that adding physician experience in working years and the PREDICT criteria, which are triggers for palliative care, to the one-year surprise question, improved the c-statistic for predicting one-year mortality.72 The studies presented in Chapters 3, 4 and 5 have confirmed that ED-visits have a trigger effect. Limitations on life-sustaining treatments were often discussed after a patient visited the ED, apparently giving food for thought about what appropriate care is. The use of risk assessment tools, and combining the surprise question with functional status, can support ED-triggered, appropriate and goal-concordant palliative care. 8.3.4. Thinking ahead to be able to act before things happen 1. A two-track approach A two-track approach assumes that a palliative care approach is concurrent with a curative care approach. Using scientific literature, including Button’s model of care, and clinical experience of clinicians who care for patients with a haematological malignancy, an integrated care model has been developed that assumes that care for patients with a life-threatening illness should not only hope for the best, but also prepare for the rest (illustrated in Chapter 4, Fig. 1).58, 73-76 Goals-of-care discussions are an essential part of both tracks. Although Chapter 4 focusses on the illness trajectory of patients with a haematological malignancy, it is probable that a two-track approach can also support patients with other serious illnesses that may still be curable. Examples are patients suffering from stroke or transient ischemic attacks, severe infections, or patients with organ failure waiting for transplantation. 8
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