Chapter one is the general introduction of this thesis. It provides the background and context to the performed research. Due to the ageing population and rising number of people suffering and dying from (multiple) chronic diseases, the need for palliative care will increase. While most patients wish to stay at home at the end of life, care transitions (especially to and from hospital) occur often. Because of these care transitions, it is important to recognize palliative care needs timely, and collaborate within and between care organizations. However, especially during hospital admissions, where focus is mainly on curative treatment, recognizing and initiating palliative care can be complex, and consequently, timely and transmural palliative care needs to be improved. Therefore, the PalliSupport program was developed. The aim of this program was to improve transmural palliative care for acutely hospitalized older adults. To do so, a transmural palliative care pathway was implemented. This care pathway comprises early identification of palliative care needs, systematic palliative care needs assessment, advance care planning, weekly multidisciplinary team meetings to which primary and secondary care professionals are invited, warm handover at hospital discharge, and follow-up home visits after discharge.
The overall aim of this thesis was to provide insight into current practice of in- hospital palliative care teams and the perspectives of both in-hospital specialists and non-specialists regarding palliative care, and to evaluate the PalliSupport transmural palliative care pathway, which was developed to overcome barriers in current practice.
Part one of this thesis focusses on current palliative care practice for acutely hospitalized older adults. Chapter two describes a quantitative descriptive study in which we assessed all specialist palliative care team consultations performed in four hospitals in the Northwestern part of the Netherlands in a six month period. The aim of this study was to provide insight into current practice of in-hospital specialist palliative care. Findings of this study show that most consultations were requested for patients with malignant diseases. Even though most consultations were requested to perform advance care planning, most consultations requests were for patients in the last weeks of their life. While most patients preferred to die at home, most patients actually died in-hospital. End-of-life preferences focused on last wishes and maintaining quality of life. This shows that consultations focus on terminal care and are more crisis-oriented than prevention-oriented.
In chapter three, the perceptions of in-hospital healthcare professionals concerning current and ideal practice of in-hospital palliative care and experienced barriers in palliative care were investigated. In this survey study, in-hospital healthcare professionals in five hospitals in the Netherlands received an electronic questionnaire. Results showed that that in current practice, palliative care and advance care planning are initiated less timely and often than what is considered ideal. A lack of inter-professional consensus was often experienced in identifying palliative care needs, and nurses also noted hesitance of physicians to introduce palliative care. Large differences between current and ideal practice for patients with functional decline were found. Nurses most often identify functional decline first, which could explain the large differences we found. Healthcare professionals believed that ideally, advance care planning should be initiated for almost all patients for whom no treatment options are left. This demonstrates the curative approach of care during hospital admissions. The differences between current and ideal practice do demonstrate the willingness to improve palliative care. Nurses could help to provide palliative care more timely and often and contribute to a more holistic approach of advance care planning. To improve in-hospital palliative care and advance care planning, a shared vision and responsibility should be created among nurses and physicians.

See dissertation for the complete summary.
Parts of the dissertation are available at https://dare.uva.nl/search?identifier=bb9ec840-ee92-40fd-b430-dd1cf449ab91