End-of-life trajectories of patients with haematological malignancies and advanced solid tumours 83 suddenly change from curative to dying: most of our patients died shortly after the EDvisit with a median survival of only 15 days. Reasons for difficulties to predict survival and to recognize the transition to the end-of-life trajectory are: possibly reversible conditions such as infections, increasing availability of systemic therapies that stimulate continuance of active treatment and increase the risk of lethal complications.1,35 Long-lasting physicianpatient relationships are also known to hamper accurate recognition of deterioration.6 The combination of these factors makes it difficult for physicians to recognize approaching death in HM-patients and to timely prepare them for their approaching death. A proactive integrated care approach We advocate, as Zimmermann, Bruera, LeBlanc, El-Jawahri, Chung and Button do, the use of an integrated care approach with two concurrent tracks: a curative approach and palliative care approach (Figure 1).16-19,36,37 Integrated care should be initiated early in the disease trajectory if the disease is potentially life-threatening (which can be at diagnosis). The first track consists of conventional disease treatment aimed at cure. The second track consists of supportive care following the four-dimensional principles of palliative care: physical, psychological, social, and spiritual. Importantly, the second track also includes discussions about future problems, treatment choices, hospital-admissions, LSTs and place of death. The palliative care approach has shown to benefit symptom-control37 and quality of life,38 to decrease ED-visits, hospital- and ICU-admissions and in-hospital deaths39,40 and might even prolong survival.41 In the integrated care approach, multidisciplinary discussions and communication across specializations within and outside the medical field are crucial to satisfy care needs. The randomized clinical trial by El-Jawahri et al. demonstrated that in-patient palliative care improved the quality of life of HM-patients already within two weeks after hematopoietic stem cell transplantation had taken place.16 4
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