Table 1.

Components of the Care Pathway for Primary Palliative Care

1. Early identification of patients eligible for palliative care, using the Surprise Question [21] and/or the Supportive and Palliative Care Indicator Tool (SPICT) [28]

2. Early assessment of patient’s needs and wishes

a. Assessment of performance status, using the Palliative Performance Scale (PPSv2) [22, 23]

b. Assessment of the patient’s needs in the biological, psychological, social and existential aspects of his or her life

c. Advance care planning

3. Interdisciplinary discussion

4. Action: delivering palliative care

5. Registration in a ‘palliative care pathway’ file, common for all team members

6. Follow-up by the team, recognizing the different stages in the palliative continuum: the ‘early palliative’ stage (the patient cannot be cured anymore), the ‘transitional’ stage (the last months) and at last the ‘dying’ stage (the last few days)