Table 2 An overview of the care pathway

Identification of palliative care needs during hospital admission

• Screening of palliative care needs based on SPICT criteria^a

• Consulting the palliative care team

• Ward nurses and department physicians

Palliative care assessment and advance care planning

• Assessment of needs, preferences, and symptoms on physical, psychological, spiritual, and social level

• Discussing treatment wishes, treatment limitations, and the patients’ preferred place of death^b

• Formulating an individualized care plan^b

• Department physician and/or palliative care team

Multidisciplinary team meeting

• Patients are discussed during weekly meetings of the transitional palliative care team, hospital specialists, and non-medical specialist

• The patients’ own GP and community nurse are invited to the meeting (in person or by phone/videoconference)^a

• The patients’ individual care plan is discussed^a

• The complexity of the patients’ palliative care situation is assessed using a colour coding system indicating stability and severity of the situation^a

• Department physician, patient’s own general practitioner, district nurse, palliative care team

Discharge

• The patient receives the individual care plan^a

• Informal caregivers receive an information sheet about support^a

• Department physician, ward nurse or palliative care team

Handover

• The patients’ GP is contacted prior to discharge or during multidisciplinary team meeting^b

• A summary of the team meeting is sent to the patients’ GP and community nurse within 24 h after discharge^b

• The medical handover is sent to the patients’ GP within 24 h after discharge^b

• Department physician, ward nurse or palliative care team

Home visit and follow-up

• The patient is visited by a member of the transitional palliative care team^a

• If needed, the patient is discussed during the team meeting, and the individualized care plan and colour code is adjusted^a

• Palliative care team