Chapter 3 64 This pragmatic study gives insight into the end-of-life trajectory of patients with advanced cancer who visit the ED. We are aware that the retrospective design of our study could have led to registration bias and unmeasured confounding. Selection bias was introduced by the choice to limit inclusion to cancer patients in the palliative phase of their disease who died within 3 months after the ED visit. We aimed to describe the population of advanced cancer patients who visited the ED at the end of their life, because especially in those patients, appropriate care should be initiated at the ED. Lastly, because the end-of-life trajectory, especially in the last 3 months, has not been subject to major changes, we consider our data collected from 2011 to 2014 still relevant to the present situation. Further research should be conducted to validate survival prediction tools and needs assessment tools for patients with advanced cancer visiting the ED and to evaluate implementation of models of ED-initiated palliative care. CONCLUSION Advanced cancer patients received limited palliative care before visiting the ED in the last 3 months of their life. The ED visit often marked physical deterioration and triggered revision of limitations on life-sustaining treatments. Many patients were hospitalized, and a substantial percentage died within 1 week and in-hospital. Timely recognition of patients at high risk of approaching death and awareness of the potential of ED-initiated palliative care among ED-staff can improve the end-of-life trajectory of these patients. Acknowledgements We would like to thank our students (Leanne Smit, Tobias Wieles, Mathijs Kruizinga and Iris Groeneveld), and Lotte van der Stap and our colleagues at the Center of Expertise Palliative Care of the Leiden University Medical Center. Author contributions Mary-Joanne Verhoef, Nanda Horeweg, Ellen de Nijs and Yvette van der Linden provided the conceptual framework for this study, analysed the data and wrote the manuscript. Marta Fiocco contributed to data-analysis. Corrie Marijnen, Anouk Jochems, Jaap Fogteloo and Christian Heringhaus contributed to data-collection and provided critical comments on the manuscript. Funding This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
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