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，没有信息的连续性，没有进一步治疗和护理提供的确定性。通常，不同环境中的医疗保健提供者之间的沟通不是最好的，这导致护理的连续性和协调性较差，对生活质量产生负面影响，并增加了可预防的住院人数。解决方案：PAL周期计划：为晚期癌症患者提供过渡性姑息治疗计划，适应当地文化和医疗体系。该方案包括一项旨在从医院护理平稳过渡到社区护理的干预措施，由五个基石部分组成：(1)与肿瘤学家和医院姑息治疗小组合作，确定有姑息和支持性护理需求的患者；(2)对患者及其家人进行同情交流；(3)在家庭护理环境中进行协作的多层面护理计划和后续行动；(4)与患者和亲属定期评估护理计划；(5)根据定期评估确定临终阶段(如果有)，根据当地的可能性和习惯，适当加强护理和临终谈话，包括就伦理和法律敏感问题与患者和家属进行磋商。计划：我们打算采用阶梯式楔形随机对照试验设计，在七个欧洲国家开发、调整、实施和评估PAL周期方案。患者、亲属和医疗保健提供者的经验，以及伦理和公平问题将用定性的方法解决。影响：PAL周期方案将促进社区护理环境中以患者为中心的癌症姑息治疗的沟通和连续性，减少计划外入院，并改善晚期癌症患者在生命末期的生活质量。

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.