Summary 229 a reminder of discussion topics. During consultations in the hospital with palliative care consultants, topics that patients and family had indicated were discussed frequently, but also topics aimed at (re)organising life at home were discussed. Using feedback of patients, family and clinicians, the LGP was adapted and an instruction leaflet was written in order to support clinicians in using the question prompt list appropriately and optimally. CHAPTER 8. GENERAL DISCUSSION Chapter 8 comprises five parts. In part 1, the studies included in this thesis are summarized. Part 2 reflects on the study methods that were used. In part 3, the implication of the findings is presented using the concept of proactive palliative care. Using the definitions for ‘proactivity’ and ‘palliative care’, three core principles of proactive palliative care can be identified: • promotion of knowledge and self-initiation in the triad of patient, family and clinician; • the intention to produce good results and avoid (future) problems; • thinking ahead to be able to act before things happen. This thesis describes how knowledge and self-initiation of the triad patients, their family and clinicians can be promoted. Medical students should be provided sufficient education to prepare them for their clinical practice, which includes patients in the last phase of their lives. Conversation guides such as the Leiden Guide on Palliative Care empower patients and family, which contributes to their knowledge and self-initiation. To have the intention to produce good results and avoid (future) problems, clinicians should have knowledge about what cues and indicators for good quality and proactive palliative are. Indicators for quality and proactive palliative care are illustrated using the example of patients with a haematological malignancy. Quality and proactive palliative care include early identification of patients visiting the Emergency Department (ED). An ED-visit can be a trigger to discuss goals of care and recognition of this trigger-function supports appropriate care. Using a two-track approach and discussing future scenarios are key components in ‘thinking ahead to be able to act before things happen’. Person-centred communication methods and conversation guides can support using a two-track approach and discussing future scenarios. The chapter further provides, from the core principles of proactive palliative care, a number of recommendations for further research (part 4) and for education, clinical practice, and policy (part 5). 9
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