Chapter 8 200 Timely initiation of a two-track approach is challenging. Known barriers to initiate palliative care conversations indicated by clinicians are, amongst others:77-79 • Lack of time to conduct such conversations properly • The patient ’s wishes and expectations are unknown • Difficulties dealing with the needs of family • Wishes and expectations of immigrant patients are unknown • End-of-life conversations can trouble the clinician-patient relationship • Feeling uncomfortable or unprepared to conduct such conversations. It seems that training and gaining experience in palliative care conversations can facilitate initiation of those conversations and the use of a two-track approach. After implementation of the serious illness communication programme of Paladino et al., nonspecialist palliative care clinicians were more aware of the necessity to initiate serious illness conversations early.80 They initiated conversations earlier in the illness trajectory, and conversations were more holistic and more multidimensional. They said they started to think more proactively. This study proves that the implementation of person-centred communication methods raises awareness among clinicians on the value of timely conversations about palliative care, and that these discussions are initiated earlier. 2. Discussing future scenarios From this thesis follows that clinicians should inform their patients to empower them and that clinicians have a professional responsibility to signal, explain, and document future scenarios. According to the Netherlands quality framework for palliative care, the discussion and reporting of current and future needs and wishes should be a standard part of proactive palliative care.19 The study in Chapter 7 revealed that patients often want to know about the future and that they do not know what the future holds for them. They are reliant on their clinicians to provide them this information in order to regain a sense of control over their care. A two-track approach demands a proactive attitude from the clinician. However, Slort et al. found that future scenarios were not anticipated by general practitioners during end-of-life conversations.81 Flierman et al. demonstrated that hospital clinicians sometimes wait for patients and family to express their wishes and preferences for the future, and do not initiate the topic themselves.82 Some clinicians in the study in Chapter 7 mentioned that the question prompt list may support them in explaining future scenarios to patients and family. Patient-reported outcome measurements (PROMs), such as the Edmonton Symptom Assessment System (ESAS), can support communication between patients, their family, and clinicians.83 Brooks et al. demonstrated that the ESAS helped them to identify and set priorities for treatment, and guided the conversation with the clinician.84 Handing out a palliative
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