Timely palliative care for older patients: From early identification to better transmural collaboration

The overall aim of this thesis was to provide scientific evidence concerning timely identification of the palliative phase, collaboration between hospitals and home, and transmural palliative care, needed for the development of the building blocks for the PalliSupport transmural care pathway intervention. An intervention aimed at improving palliative care for older patients, lowering unwanted hospital admissions and increasing the number of patients dying at their preferred place.
In the first part of this thesis we looked at how hospital-based professionals identify the palliative phase and if identification instruments could help. We found that identification is a relatively unstructured process and that difficulties occur because of a persistent focus on treatment, the unpredictability of diseases, and obstacles in communication with patients and in the collaboration with other professionals. We further found that identification instruments do not have sufficient prognostic accuracy to be used as a method to determine one year mortality in acutely hospitalized older patients.
In part II of this thesis we focused on transmural collaboration in palliative care. We found that currently handover between hospital and home is hindered by lack of identification, focus on solely physical aspects, lack of direct communication, and uncertainty in responsibilities. A literature study found that transmural team-based palliative care interventions can reduce the number of hospital admission and improve the number of patients dying at their preferred place. Furthermore, we performed a feasibility study of the PalliSupport transmural care pathway intervention which led to the adjustment of the protocol prior to the effectiveness trial.