General discussion 205 of the illness trajectory, or six months or one year for more upstream evaluation of the palliative phase of the illness trajectory.19 Early palliative care is preferable to timely prepare patients with a (potentially) lifethreatening illness and their family. However, a proactive palliative care approach can also be initiated later in the illness trajectory, which is especially imaginable in patients with illness trajectories that are difficult to predict. Kripp et al. have constructed a prediction score for approaching death consisting of low performance status (ECOG score >2), low platelet count (<90×10−9/L), opioid treatment for pain (WHO level 3), high plasma LDH (>248U/L) and low plasma albumin (<30g/L).96 Using these predictors, three risk groups can be identified: low risk (presence of no or one predictor; median survival of 440 days); intermediate risk (two or three predictors; median survival of 63 days); and high risk (median survival of 10 days). The Kripp prediction score can support identification of patients with palliative care needs and differentiate in urgency of their needs. However, this study was conducted in patients who were admitted to a palliative care unit, suggesting that these patients were already identified as having palliative care needs. Validation of the Kripp prediction score in a prospective cohort study in patients admitted to the haematology ward is needed to know whether the Kripp prediction score can be used to identify patients with approaching death. 2. Timely identification of palliative care needs: ED-triggered palliative care in patients with advanced cancer An ED-visit can be a trigger to initiate proactive palliative care.65 In Chapter 3 and Chapter 4, it seems that the ED-visit triggered discussions about limitations on lifesustaining treatments. A prospective cohort study in patients identified at the ED using the surprise question can provide insight into 1) whether ED-visits increase the number of documentation of goals-of-care discussions, and 2) goal concordance of care following the ED-visit. The trigger card presented in Chapter 3 included risk factors for approaching death in patients with advanced cancer. To validate the trigger card and to identify other predictors for approaching death, a prospective cohort study can be conducted in patients with a diagnosis of advanced cancer (without curative treatment options or with curative treatments with a substantial risk of mortality). ‘Death’ can be a candidate outcome measure to identify predictors for patients in the dying phase. However, ‘death within three months’ could be more clinically relevant in organising appropriate palliative terminal care at the place patients and their family would prefer. Chapter 5 demonstrated that patients with advanced cancer, about whom the clinician would not be surprised if they died within one year, and who have a poor physical 8
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