General discussion 207 8.4.3 Thinking ahead to be able to act before thing happen 1. A two-track approach A two-track approach as described in Chapter 4 and in paragraph 8.3.4.1 of this chapter can improve proactive care by concurrent tracks of curative care and palliative care. To develop a two-track model of care in a haematology department, a participatory action research (PAR) approach can be used. The development of a two-track model of care as a working method using PAR not only provides insight into how the model works in clinical practice, but also aims at implementing the model into daily care. It is therefore essential to make arrangements with all involved stakeholders, including the generalist palliative care responsibilities of haematology clinicians and the specialist palliative care responsibilities of palliative care consultants. These responsibilities are described by Henderson et al.25 Additionally, haematology clinicians should be educated about generalist palliative care in the context of their responsibilities in the palliative care track. The description of the two-track care model as a working method and how it can be implemented can support hospital wards to start working with a two-track care model. Using the quality indicators of paragraph 8.3.3.1, the quality of care can be evaluated before and after implementation of the two-track care model. The implementation should ideally be part of a cluster randomised trial, in which haematology wards of multiple hospitals are randomised to either standard care or the two-track care model. The primary outcome should be the quality of life, and potential secondary outcomes are multidimensional symptom burden, satisfaction with care and goal concordance of care. The haematology palliative care model as described by Button (paragraph 8.3.3.1) assumes that all patients with a haematological malignancy need a palliative care approach because of the high mortality risk due to either the illness or the treatment.58 The Button model is probably also appropriate in other illnesses that have a similar trajectory, for example aggressive but treatable carcinomas such as advanced stage melanomas, or osteosarcomas and pancreatic carcinomas that may be treated with surgery but may also have metastasized. Also non-cancer patients may have a ‘haematology-like’ trajectory, for example patients with serious infections acquiring intensive treatment and patients with organ failure waiting for transplantation. The aforementioned two-track care model could also be researched using PAR to develop and implement a working method for concurrent palliative care for these patients. A two-track approach demands a proactive attitude in discussing palliative care needs. In Chapters 3, 4 and 5, cues for proactive palliative care were used to study the end-of-life trajectories of patients with advanced cancer or a haematological malignancy visiting the ED (see also paragraph 8.3.3.1). This list should be evaluated and complemented in 8
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