Table 1 Nine core elements and associated standards of palliative care according to the Netherlands Quality Framework for Palliative Care [25]

1. Identification

Patients in need of palliative care are identified in a timely matter.

2. Shared decision-making

Shared decision making is incorporated in palliative care as a continuous process in which care is tailored to the individual’s situation and to the achievable values, wishes and needs of individual patients and their relatives.

3. Advance care planning

Advance care planning is addressed in a timely manner and decisions are recorded in the individual care plan. When the situation requires this, plans will be adjusted.

4. Dimensions of palliative care

 - Physical

 - Psychological

 - Social

 - Spiritual

Physical: The physical symptoms of a patient with a life-threatening condition or vulnerability are treated in accordance with applicable guidelines, which may be deviated from on the basis of knowledge and expertise, and treatment is tailored to individual patients. Medical instruments and resources must be available in sufficient quantities.

Psychological: Together with the patient and their relatives, the care provider pays attention to the psychological consequences of a life-threatening condition or vulnerability and the presence of any psychiatric symptoms.

Social: The care provider, together with the patient and their relatives, considers their social context, in order to meet their goals, wishes and needs. In this way, strengths can be used and the well-being of the patient and their relatives can be enhanced.

Spiritual: Attention is focused on what is meaningful for the patient and their relatives and appropriate support is provided for spiritual and existential questions and needs.

5. Expertise

Professionals are qualified for the care they provide and keep their knowledge up to date with relevant training.

6. Coordination and continuity

A personal and dynamic team of professionals is formed around the patient and their relatives, who are available at all times. This team works on the basis of the individual care plan, with the central care provider as the connecting link.

7. Cooperation with other organisations

Relevant organisations within the same region work together effectively and efficiently to meet the wishes and needs of patients with a life-threatening condition or vulnerability and the wishes and needs of their relatives.

8. Individual care plan

Each patient in the palliative phase has an individual care plan that accompanies the patient and is adjusted if necessary during the disease process. The individual care plan includes agreements that are readily accessible, also during nights, weekends, in crisis situations and in the dying phase.

9. Support for professionals

Professionals are aware of the emotional impact of providing palliative care. They reflect on their own attitude and actions and have an eye for their personal balance.