Kwetsbaarheid en/of ongeneeslijke aandoening met een levensverwachting van minder dan een jaar Life threatening disease and frailty
Conditions
Interventions
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
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
Sponsors
Academisch Medisch Centrum
Eligibility
Age
18 Years to 99 Years
Inclusion criteria
Inclusion criteria: 1) Age (*65 years); 2) Acutely admitted for *48 hours to the departments of internal medicine, geriatrics, cardiology, pulmonary disease, gastroenterology or oncology; 3) Positive SPICT* criteria*: a hospital admission in six months prior to admission, functional status decline and weight loss (65-79 years: two or more positive criteria, >80 years: 1 or more positive criteria); 4) Ability to read and speak the Dutch language;
Exclusion criteria
Exclusion criteria: Patients who are not able to answer questionnaires due to severe cognitive impairment (MMSE
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| The primary outcome is the occurrence of (at least one) unplanned hospitalisation in the six months after discharge. | — |
Secondary
| Measure | Time frame |
|---|---|
| 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. | — |
Countries
Netherlands
Outcome results
None listed