Table 1 Components of the intervention

Identification of palliative care needs during admission

• Identification of palliative needs based on Surprise Question and ≥ 2 SPICT criteria*

• Palliative Care team is consulted

Department nurses and physicians

Palliative care assessment and advance care planning

• Assessment of needs, preferences and symptoms on (1) physical, (2) psychological, (3) social and (4) spiritual level

• Discussion of treatment limitations⁺

• Discussion of preferred place of death⁺

• Formulating individualized care plan⁺

Palliative care team and/or department physician

Multidisciplinary team meeting

• Weekly discussions about patients with the palliative core team, hospital specialists and non-medical specialist

• Invitation GP and community nurse (either in person or by phone)*

• Discussing individualized care plan*

• The complexity of the patient’s palliative care situation is assessed using the new working methods (colour coding indicating the stability and severity of the problems) *

Palliative care team, department physician, GP, community nurse

Discharge

• Patient receives individualized care plan*

• Informal caregiver receives information sheet about support*

Palliative care team or department physician/nurse

Handover

• Contact with GP at least once prior to discharge/during MDT meeting⁺

• MDT summary is sent to GP and/or community nurse within 24 h of discharge⁺

• Medial handover is send to GP within 24 h of discharge⁺

Palliative care team and/or department physician/nurse

Home visit and follow-up

• Home visits at place of care*

If applicable

• Follow-up discussion at MDT*

• Adjustment of individualized care plan*

• Adjustment of colour coding*

Palliative care team