Table 1.

Components of the intervention

Intervention	Components	Intervention conducted by
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

*Components that were completely new within the intervention

⁺Components that were already performed for some patients but should be done for all patients during the study