General discussion 211 2. Timely identification of palliative care needs: ED-triggered palliative care in patients with advanced cancer ED-visits can be a trigger for the initiation of palliative care and can improve the quality of life.64, 66 Using the results in Chapter 3, and a report on care in the last phase of life in patients with advanced colon or lung cancer of by the Netherlands Care Institute (Zorginstituut Nederland), a trigger card was constructed that can support timely recognition of patients with advanced cancer at high risk of approaching death.68 The trigger card supports taking directed actions in patients with urgent palliative care needs visiting the ED and can be implemented in the ED with help from a palliative care consultation team. Palliative care specialists should give instructions on how to use the trigger card, when to conduct goalsof-care discussions, and when to refer to specialist palliative care. In Chapter 4, the predictive value of the surprise question (SQ) and the addition of other potential predictors for palliative care needs were studied. The SQ plus performance score of 3 or 4 according to the Eastern Cooperative Oncology Group (ECOG) can help differentiate in the urgency of palliative care needs in patients with advanced cancer. The clinical implications for using SQ plus ECOG 3-4 are summarised below (Table 1). Table 1. Differentiating in urgency of palliative care needs in patients with advanced cancer visiting the emergency department, using the Surprise Question and functional status (using the ECOG classification), and appropriate actions Patients with advanced cancer Median survival Actions Step 1: Surprise Question NS 3 months Initiate symptom-management and focus care on quality of life Step 2: ECOG NS + ECOG 0-2; S 6 months Initiate a two-track approach by complementing diseasemodifying treatment with conversations about the potential end of life and the patient ’s wishes to prepare patients and family NS + ECOG 3-4 1 month Initiate end-of-life care according to the patient ’s wishes as soon as possible Abbreviations: S: surprised; NS: not surprised; ECOG: Eastern Cooperative Oncology Group After identification of patients who can benefit from a palliative care approach, they should be screened for symptoms or problems in a multidimensional way. George et al. developed a tool to screen for multidimensional palliative and end-of-life care needs in the ED, derived from a systematic review and shortened: 5-SPEED.101, 102 (5-SPEED):103 1. pain management: how much are you suffering from pain? 2. home care: how much difficulty are you having getting your care needs met at home? 3. medication management: how much difficulty are you having with your medications? 8
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