PALliative Care Yields Cancer welLbEing Support

挑战：许多晚期癌症患者在生命的最后阶段离开医院时，没有连续性的信息，也没有进一步治疗和护理的确定性。通常，不同环境中的医疗保健提供者之间的沟通不够理想，这导致护理的连续性和协调性差，对生活质量产生负面影响，并增加了可预防的住院率。解决方案：PAL-CYCLES计划：针对晚期癌症患者的过渡性姑息治疗计划，适应当地文化和卫生保健系统。该方案包括一项旨在从医院护理顺利过渡到社区护理的干预措施，包括五个基本组成部分：(1)与肿瘤学家和医院姑息治疗小组合作，确定患者是否需要姑息治疗和支持性护理；(2)与患者及其家属进行富有同情心的沟通；(3)协作式多维照护计划与居家照护跟进；(4)与患者及家属定期评估护理计划；(5)在定期评估的基础上确定临终阶段（如果有的话），根据当地的可能性和习惯，适当加强护理和临终谈话，包括与患者和家属就道德和法律敏感问题进行磋商。计划：我们打算在七个欧洲国家采用阶梯楔形随机对照试验设计开发、调整、实施和评估PAL-CYCLES项目。病人，亲属，和卫生保健提供者的经验，以及道德和公平问题将与定性的方法来解决。影响：PAL-CYCLES方案将促进社区护理环境中以患者为中心的沟通和癌症姑息治疗的连续性，减少计划外住院，并改善晚期癌症患者临终时的生活质量。

Challenge: many patients with advanced cancer in the final phase of life leave the hospital without continuity of information, and certainty about further treatment and care provision. Often, communication between healthcare providersin differentsettingsissuboptimal and this leads to poor continuity and coordination of care, negatively impacting the quality of life and increasing preventable hospital admissions. Solution: the PAL-CYCLES programme: a transitional palliative care programme for patients with advanced cancer, adaptable to local cultures and healthcare systems. The programme contains an intervention aiming for a smooth transition from hospital care to community care, consisting of five cornerstone components: (1) identification of a patient with palliative and supportive care needs in collaboration with the oncologist and the hospital palliative care team; (2) compassionate communication towards the patient and their family; (3) a collaborative multidimensional care plan and follow-up in the home care setting; (4) periodic evaluation of the care plan with patients and relatives; (5) identification of the terminal phase (if there) based on the periodic evaluations, with appropriate intensification of care and end-of-life talks depending on local possibilities and habits, including consultation with patient and families about ethically and legally sensitive issues. Plan: we intend to develop, adapt, implement, and evaluate the PAL-CYCLES programme in seven European countries using a stepped wedge randomized controlled trial design. Patient, relatives, and health care provider experiences, as well as ethical and equity issues will be addressed with qualitative methods. Impact: the PAL-CYCLES programme will facilitate patientcentred communication and continuity of palliative cancer care in the community care setting, reducing unplanned hospital admissions and improving quality of life for patients with advanced cancer at the end of life.