Summary 227 received more aggressive end-of-life care and were more frequently hospitalized after their ED-visit. They died more frequently in-hospital, in the intensive care unit or in the ED. To aid both patients and ED-staff, we recommend implementing a two-track approach, a care model for early integration of palliative care concurrent with curative haematological treatment. The two-track approach aims at preparing patients with a haematological malignancy for death as a possible outcome of either their life-threatening disease or heavy treatment in a timely matter, when they can still express their wishes. CHAPTER 5. SURPRISE QUESTION AND PERFORMANCE STATUS INDICATE URGENCY OF PALLIATIVE CARE NEEDS IN PATIENTS WITH ADVANCED CANCER AT THE EMERGENCY DEPARTMENT: AN OBSERVATIONAL COHORT STUDY The Surprise Question (SQ), ‘ ‘Would I be surprised if this patient died within one year?’ ’, is an instrument to identify patients with palliative care needs.14 The SQ is asked and answered by the clinician. An “not surprised” (NS)-answer is indicative for potential palliative care needs, which should be further assessed. A meta-analysis by Downar et al. demonstrated that SQ may not be a sufficient screening tool for death within one year in the overall population of patients with advanced cancer.23 It lacked sensitivity and, therefore, under-estimated the number of patients with palliative care needs. The SQ may be more accurate combined with other indicators of palliative care needs, such as symptoms prevalent in the palliative phase, performance status, and indicators of increased utilization of formal and informal care. Chapter 5 includes an observational cohort study in 245 patients with advanced cancer visiting the ED in 2013 and 2014 to evaluate the test characteristics of the SQ. The addition of other clinical factors predictive of death was studied to find if these can improve the SQ’s test performance. The results show that the SQ had the following test characteristics: sensitivity of 89%, specificity of 40%, positive predictive value of 85%, negative predictive value of 50% and a c-index of 0.56. In patients in whom physicians would not be surprised if they died within one year, ECOG performance status 3-4 was an independent predictor for approaching death. Addition of ECOG performance status 3-4 as a second step to the SQ improved the c-index (0.65), specificity (92%) and positive predictive value (95%) at cost of sensitivity (40%) and negative predictive value (29%). Performance status can be a valuable addition to the SQ to differentiate in prognosis and thus in urgency of palliative care needs. In the ED, the combination of first, the SQ, and second, performance status, can function as a trigger to start palliative care according to patient ’s wishes. A model including the SQ and performance score was constructed to support which actions are appropriate for which urgency of palliative care needs in patients with advanced cancer visiting the ED. 9
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