Chapter 9 226 CHAPTER 3. PALLIATIVE CARE NEEDS OF ADVANCED CANCER PATIENTS IN THE EMERGENCY DEPARTMENT AT THE END OF LIFE: AN OBSERVATIONAL COHORT STUDY Insight in the end-of-life trajectories of patients with advanced cancer visiting the Emergency Department (ED) is of added value in the context of ED-triggered palliative care. Chapter 3 describes a mortality follow-back study in 420 patients with advanced cancer who visited the ED up to three months before they died. This study showed that patients with advanced cancer often visited the ED while their care was still focused on disease modification. Only a few patients had limitations on life-sustaining treatments. This may have led to a high percentage of hospitalisations and in-hospital deaths in this study. Factors associated with approaching death were lung cancer, neurologic deterioration, dyspnoea, hypercalcemia, and jaundice. We concluded that timely recognition of patients at high risk of approaching death can improve end-of-life care in patients with advanced cancer. To facilitate timely recognition, a flowchart was constructed which supports taking directed actions in patients with advanced cancer and urgent palliative care needs in the ED. CHAPTER 4. END-OF-LIFE TRAJECTORIES OF PATIENTS WITH HAEMATOLOGICAL MALIGNANCIES AND PATIENTS WITH ADVANCED SOLID TUMOURS VISITING THE EMERGENCY DEPARTMENT: THE NEED FOR A PROACTIVE INTEGRATED CARE APPROACH ED-triggered palliative care can avoid potentially inappropriate end-of-life care.12, 13 Patients with a haematological malignancy more frequently receive aggressive end-of-life care than patients with a solid tumour.22 Insight into cues for proactive care can help improving EDtriggered palliative care in patients with a haematological malignancy. Chapter 4 presents a mortality follow-back study in 78 patients with a haematological malignancy and 420 patients with a solid tumour visiting the ED in the last three months of life. The aim was to compare the end-of-life trajectories and quality of end-of-life care between these patients using five of Earl et al.’s quality indicators of end-of-life care: intensive anticancer treatment <3 months, ED visits <6 months, in-hospital death, death in the intensive care unit (ICU), and in-hospice death. Cues for proactive care were 1) communication about the patient’s condition between a hospital clinician or palliative care consultation team and the patient’s general practitioner; 2) proactive care plans; 3) and limitations on life-sustaining treatments before the current ED-visit. Before their ED-visits, patients with a haematological malignancy had less frequently discussed limitations on life-sustaining treatments than patients with a solid tumour. Since their ED-visit, patients with a haematological malignancy
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