Chapter 4 74 of life; starting a new chemotherapy in the last 30 days of life; >1 emergency room visit in the last month of life; >1 hospitalization in the last month of life; ICU-admission in the last month of life; death in an acute care hospital; lack of hospice-admission; admission to hospice <3 days before death.24,25 The primary objective of this study was to provide insight into the end-of-life trajectory of HM-patients visiting the ED during the last three months of life and to compare with ST-patients. Secondary objective was to compare the quality of end-of-life care in HM- and ST-patients. PATIENTS AND METHODS Setting This mortality follow-back study was conducted at Leiden University Medical Center (LUMC) in Leiden, the Netherlands. LUMC’s ED is open 24 hours a day, 7 days a week. On average, 80 patients visit the ED every day and about 30.000 patients are evaluated every year. Since 2011, LUMC has a palliative care consultation team (PCCT), which is available to all departments of our centre for consultation after patients are referred by their health care professional. This study was part of a larger study on end-of-life trajectories of all patients visiting the ED between 2011 and 2013, approved by LUMC’s Committee of Medical Ethics on May 27, 2013. Written consent was not required according to Dutch Law (WGBO, article 458) and European Law (General Data Protection Regulation). Patients All adult HM-patients who died within three months after their last ED-visit were included. They were compared to ST-patients with advanced cancer, which was defined as not having any curative options or receiving anti-cancer treatment not aimed at curation. Detailed analysis of ST-patients is published elsewhere.26 The period of three months was chosen because in the Netherlands, an estimated life-expectancy of <3 months justifies referral to intensive palliative care at home, in nursing homes and in hospices. Datacollection occurred from May 2011 - January 2013. Data collection For transparent and solid data collection, a code book was designed by two members of our PCCT which contained inclusion and exclusion criteria and description and coding of all variables.27 Characteristics of disease, referral, ED-visit, and follow-up from ED-arrival until death were extracted from electronic patient records (EPRs) of eligible patients by four trained research assistants. One expert of the PCCT checked
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