PalliSupport: a transitional care pathway for elderly patients at the end of life

Inadequate palliative care for elderly patients can result in unplanned hospitalisation, reduced quality of life and patients not dying at their place of preference. Barriers to appropriate palliative care can be found at the organisational, communicational, educational and cultural levels. The aim of the The PalliSupport care pathway is to overcome these barriers by providing patient-centred care by means of timely identification of patients who could benefit from palliative care, a comprehensive palliative assessment and follow-up until death. Furthermore, PalliSupport aims to enhance knowledge of health care providers and improve collaboration between care settings.
The primary objective is to evaluate the effect of the PalliSupport care pathway on unplanned hospital readmission, deaths at place of preference, quality of life, symptom burden and informal caregiver burden.



This study will be a pragmatic multicentre stepped-wedge randomised trial (SW-RCT) in 5 hospitals and surrounding regions (clusters). 300 patients will be included in the care a usual phase and 300 in the intervention phase.



Study population: Dutch-speaking patients aged ≥ 65, acutely admitted for 48 ≥hours to the departments of internal medicine, geriatrics, cardiology, pulmonary disease, gastro-enterology or oncology, and found eligible for palliative care, as determined by the Surprise Question (SQ) and Supportive Palliative and Palliative Care Indicators Tool (SPICT) criteria.



Intervention: The intervention consists of a transitional care pathway that starts during an acute hospitalisation. The intervention consists of timely identification with the Surprise Question and SPICT criteria. After identification, conversations about end-of-life preferences will be initiated and an integral palliative assessment will be performed by the palliative care team. The patient will be discussed in a weekly multidisciplinary team meeting (MDT), which is attended by the patient’s primary care physician and home care nurse, and an individualised palliative care plan will be formalised. During the MDT the intensity of follow-up will be determined. Before discharge the patient and their informal caregiver will receive a copy of the individualised care plan; a copy will also be sent to the primary care physicians and home care services. After discharge the patient is followed up by the palliative care team and discussed in the MDT until this is deemed no longer necessary. Primary care professionals can consult the palliative care team again if new problems occur.
The primary outcome is the occurrence of (at least one) unplanned hospitalisation in the six months after discharge. Secondary outcomes are dying at the place of patient’s preference. Furthermore, the quality of life, symptom burden, palliative outcomes, caregivers’ burden and health care utilisation will be assessed.

Inadequate palliative care for elderly patients can result in unplanned hospitalisation, reduced quality of life and patients not dying at their place of preference. Barriers to appropriate palliative care can be found at the organisational, communicational, educational and cultural levels. The PalliSupport care pathways aims to overcome these barriers by providing patient-centred care by means of timely identification of patients who could benefit from palliative care, a comprehensive palliative assessment and follow-up until death. Furthermore, PalliSupport aims to enhance knowledge of health care providers and improve collaboration between care settings.

Patients will be asked to answer questionnaires at baseline, two weeks after discharge, one, three and six months after discharge (or until death).

A transtional palliative care pathway. The transitional care pathway starts during admission and follows patients both in primary and secondary care.