Table 2.
Identified bottle necks and challenges
| Capacity and resources |
| The patient has no GP |
| Low engagement from the GP regarding patients with terminal illness |
| Lack of hospital inpatient capacity |
| Access to healthcare personnel with specialist competence in palliative care |
| Dying patients in the communities require resources |
| Coordination and responsibility |
| Communication between the levels due to different ICTa system |
| Lack of continuity when the patients are admitted to the ERb |
| Insecurity regarding who is in charge of the patient; who receives the discharge report from the hospital |
| GP must coordinate referrals to various hospital departments |
| Return to hospital after discharge without passing by ER—how should it be practiced? |
| Updated medication lists when the patient is admitted to or discharged from hospital are often lacking |
| Competency |
| The content of the discharge reports regarding palliative care is inadequate |
| Inadequate documentation: What is discussed with patient and carer regarding treatment options? |
| Lack of competence in palliative care |
| Difficult for the GP to know when a cancer patient is in a palliative setting |
aICT Information and communications technology systems
bER Emergency room