EARLY IDENTIFICATION OF PATIENTS IN NEED OF PALLIATIVE CARE  
IN SLOVENIAN GENERAL PRACTICE
Lisette KLOK1*, Yvonne ENGELS2, Carel VELDHOVEN2, Danica ROTAR PAVLIČ3
1Radboud University Medical Center, Faculty of Medicine, Regenwulp 19 Breda, 4822 RJ, the Netherlands
2Radboud University Medical Center, Department of Anaesthesiology, Pain and Palliative Medicine,  
Nijmegen, the Netherlands
3University of Ljubljana, Faculty of Medicine, Department of Family Medicine,  
Poljanski nasip 58, 1000 Ljubljana, Slovenia
Received: Apr 19, 2017
Accepted: Jan 15, 2018
Original scientific article
Background: To help general practitioners (GPs) in early identification of patients with palliative care (PC) 
needs, this pilot study aimed to determine the potential of the combined original surprise question (SQ1) 
(‘Would I be surprised if this patient died within the next 12 months?’) and the second surprise question (SQ2) 
(‘Would I be surprised if this patient was still alive after 12 months?’). We hypothesized that answering these 
SQs would trigger them to make a multidimensional care plan.
Methods: 26 Slovenian GPs, randomized into 4 groups, were invited to write a care plan for each of the four 
patients described in case vignettes (2 oncologic, 1 organ failure and 1 frailty case). GPs in group 1 were only 
asked to write a care plan for each patient. GPs in group 2 answered SQ1 and GPs in groups 3 and 4 answered 
SQ1 and SQ2 before writing the care plan. The type and number of PC aspects mentioned in the respective care 
plans were quantified into a numeric RADboud ANTicipatory (RADIANT) score.
Results: Mean RADIANT scores in groups 1-4 were 2.2, 3.6, 2.5 and 3.1, respectively. When comparing the 
different vignettes, vignette B (terminal oncologic patient) scored best (3.6). Mean RADIANT scores in groups 3 
and 4 were slightly higher for GPs who would be surprised compared to GPs who would not be surprised if the 
patient was still alive in 12 months.
Conclusion: The combined SQs were considered helpful in the early identification of patients in need of PC in 
Slovenian general practice.
Uvod: Namen te študije kot pomoč splošnim zdravnikom (SZ) pri zgodnjem prepoznavanju pacientov s potrebo 
po paliativni oskrbi (PO) je določanje potenciala kombiniranega izvirnega vprašanja presenečenja (VP1): »Ali bi 
me presenetilo, če bi pacient umrl v naslednjih 12 mesecih?« ter drugega vprašanja presenečenja (VP2): »Ali bi 
me presenetilo, če bi bil ta pacient živ čez 12 mesecev?« Naša hipoteza temelji na domnevi, da bi odgovarjanje 
na ti dve VP sprožilo pripravo večdimenzionalnega načrta oskrbe.
Metode: Šestindvajset slovenskih SZ, ki so bili naključno razvrščeni v štiri skupine, smo prosili, naj pripravijo 
načrt oskrbe za vsakega od štirih pacientov, ki so bili opisani v vinjetah s primeri (2 onkološka primera, 1 
odpoved organov in 1 primer krhkosti). SZ v 1. skupni so morali napisati poročilo o oskrbi za vsakega pacienta. 
SZ v 2. skupini so odgovorili na VP1, SZ v 3. in 4. skupini pa so odgovorili na VP1 in VP2, preden so pričeli 
pripravljati načrt oskrbe. Vrsta in število stališč PO, ki so bili omenjeni v načrtih oskrbe, so bili izmerjeni v 
numerični rezultat RADboud ANTicipatory (RADIANT).
Rezultati: Povprečni rezultati RADIANT od 1. do 4. skupine so bili 2,2, 3,6, 2,5 in 3,1. Pri primerjanju različnih 
vinjet je vinjeta B (umirajoči onkološki pacient) pridobila najboljši rezultat (3,6). Povprečni rezultati RADIANT 
v 3. in 4. skupini so bili rahlo višji pri SZ, ki bi bili presenečeni, v primerjavi s SZ, ki ne bili presenečeni, če bi 
bil pacient še vedno živ čez 12 mesecev.
Zaključek: Kombinirana VP pripomorejo k zgodnjemu prepoznavanju pacientov s potrebo po PO v splošni 
zdravstveni oskrbi v Sloveniji.
ABSTRACT
Keywords: 
palliative care, surprise 
question, general 
practitioners, Slovenia, 
cancer, organ failure, 
frail elderly, dementia
IZVLEČEK
Ključne besede: 
paliativna 
oskrba, vprašanje 
presenečenja, splošni 
zdravniki, Slovenija, 
rak, odpoved 
organov, krhkost pri 
starostnikih, demenca
*Corresponding author: Tel. + 316 241 89 472; E-mail: lisette_klok@live.nl
10.2478/sjph-2018-0008 Zdr Varst. 2018;57(2):55-64
55
ZGODNJE PREPOZNAVANJE PACIENTOV S POTREBO PO PALIATIVNI OSKRBI  
V SPLOŠNI ZDRAVSTVENI OSKRBI V SLOVENIJI
Klok L, Engels Y, Veldhoven C, Rotar Pavlič D. Early identification of patients in need of palliative care in Slovenian general practice. 
Zdr Varst. 2018;57(2):55-64. doi: 10.2478/sjph-2018-0008.
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 INTRODUCTION
During advanced stages of chronic life-limiting diseases, 
patients might benefit from palliative care (PC). Many 
patients in the Western world wish to remain at home 
during this palliative phase and to die there. Therefore, 
general practitioners (GPs) should play an important role 
in PC provision (1-4). In Slovenia, this is challenging since 
the average consultation time per patient is 7 minutes, 
and GPs do not receive extra payment for home visits (5). 
Other barriers in PC provision are the lack of knowledge, 
PC skills and experience, suboptimal communication with 
patients and with other healthcare professionals, and the 
uncertainty and unpredictability of illness trajectories, 
especially in non-cancer illnesses. (6-10). Therefore, 
PC is often restricted to physical symptom relief in 
the terminal phase, including emergency visits by the 
GP, transfers and unplanned hospital admissions (11). 
Moreover, 4% of the elderly Slovenian population have 
severe limitations, for which they do not receive any care 
(12). Without a universally accepted definition of ‘early’ 
palliative care, the dilemma arises of marking the right 
moment to start anticipatory PC alongside or instead of 
disease-oriented care in the advanced stages of chronic 
diseases (13-14). Physicians can approach this dilemma by 
(silently) asking themselves the surprise question (SQ1): 
‘Would I be surprised if this patient died within the next 
12 months?’ PC, including anticipating future problems, 
needs and wishes, would be indicated if the answer to 
this question was ‘no.’ The usefulness of this SQ has been 
validated in different populations (15-17). However, two 
recent reviews conclude that there is a wide range in 
accuracy and that further research is needed to develop 
more accurate tools (18, 19). Therefore, the second SQ 
(SQ2) was formulated: ‘Would I be surprised if this patient 
was still alive in 12 months?’ The aim of this pilot study 
was to determine the potential of using both SQ1 and SQ2 
as tools to help GPs in the early identification of patients 
with a high chance to deteriorate or die. 
2 METHODS
2.1 Population
In June 2016, invitations to participate in this study were 
sent to 240 recipients of the Slovenian Family Medicine 
Journal in the Ljubljana area, all being registered GPs. 
Because of the lack of responses, another 39 GPs from all 
over Slovenia, of whom the email addresses were know by 
one of the authors (DRP), were invited one month later. 
All responses were gathered in July and August 2016.
2.2 Design
Participating GPs were randomized into four groups and 
were sent the matching questionnaire through the valid 
online software application CastorEDC. Each questionnaire 
contained the same four case vignettes based on real 
patients’ cases that were adapted to guarantee anonymity. 
The vignettes were written in English and described one 
organ failure patient (Vignette A), one terminal oncology 
patient (Vignette B), one frail elderly patient with 
dementia (Vignette C), and one incurable, but not yet 
terminal oncology patient (Vignette D) (Appendix 1). GPs 
in the first group were only asked whether they would plan 
any care for each of these patients. Those who decided 
to initiate care were asked to describe their care plan in 
detail. The GPs in group 2 were asked to answer SQ1. GPs 
in groups 3 and 4 were asked to answer SQ1 and SQ2 before 
answering the questions as described for the first group. 
GPs in group 4 were also shown the problem square (PS), a 
document designed to help structuring multidimensional 
care planning (Figure 1), before describing their care 
plan (20). Lastly, GPs were asked which aspects generally 
trigger them to start PC, and they were asked to give their 
opinion on the helpfulness and usefulness of the SQs and 
PS. The care plans and opinion section could be written in 
English or in Slovenian. Slovenian answers were translated 
to English by an independent, native Slovenian speaker.
10.2478/sjph-2018-0008 Zdr Varst. 2018;57(2):55-64
56
Figure 1. Problems square (Thoonsen et al. 2011 (18)).
2.3 Data Management
The open text content of each PC plan was quantified into 
a numeric score, the RADboud ANTicipatory (RADIANT) 
score, by one author (C.K.), using a score form (Figure 2). 
The form was developed by researchers from the Radboud 
university medical centre based in the Netherlands, on the 
WHO definition of PC and Dutch palliative care guidelines 
(21-24). The maximum score was 20 points.
10.2478/sjph-2018-0008 Zdr Varst. 2018;57(2):55-64
57
The primary outcome measure was the answer combination 
given to SQ1 and SQ2 in relation to the RADIANT scores for 
each care plan. The secondary outcome measures were:
• Differences in RADIANT scores between the four study 
groups and between the four vignettes.
• Proportion of multidimensional care plans in each 
study group and each vignette.
• Proportion of reactive and anticipatory care plans per 
vignette within each group.
• Differences in mean RADIANT scores between care 
plans written in Slovenian and in English.
• A qualitative review regarding the aspects that 
trigger GPs to start PC as well as their opinions on 
the usefulness of the SQs and PS.
All calculations were made using IBM SPSS software version 
22. Significance testing was not performed because of the 
explorative nature of this study with a limited number of 
subjects.
3 RESULTS
3.1 Population
297 GPs were invited to participate in this study. 35 
(11.8%) agreed to participate, and 26 (8.8% of total, 
74% of those who agreed) actually completed the survey 
(Figure 3). The participants’ characteristics are shown in 
Table 1.
Table 1. Characteristics of participants.
Age  (years±SD)
Gender: male 
Vocational training 
Function
• Employee in Healthcare Center
• Independent contract holder
• Employee in practice of independent  
   contract holder
• Other
Type of practice
• Practice in healthcare center
• Solo practice
• Nursing home
• Other
Teaching practice 
Workload (hours per week ±SD)
After hours work (hours per month ±SD)
Consultation time (minutes per patient ±SD)
Home visits (no. per week ±SD)
Interest in palliative care (scale 1-10 ±SD)
Palliative care skills ( scale 1-10 ±SD)
Plans to improve PC skills 
48±10.4
36%
96%
56%
20%
20%
4%
56%
32%
8%
4%
64%
37±11.0
20±13.7
9.5±4.9
0.9±1.0
8.4±1.1
6.3±1.6
93%
Figure 2.
Figure 3.
Score form.
The process of inclusion of general practitioners.
10.2478/sjph-2018-0008 Zdr Varst. 2018;57(2):55-64
58
3.2 Primary Outcome
In group 2, all participants (n=8) answered SQ1 with ‘no’ 
for each vignette (Table 2). In groups 3 (SQ1 and SQ2) 
and 4, (SQ1, SQ2 and PS) the patient B (terminal oncology 
patient) was the only patient for whom all GPs gave the 
answer combination no + yes (they would not be surprised 
if the patient died and would be surprised if the patient 
was still alive in 12 months). For the patient C (frail 
elderly patient with dementia), none of the GPs in group 
3, and only 1 GP in group 4, gave this answer combination. 
In groups 3 and 4, the mean RADIANT scores were slightly 
higher for GPs who would be surprised if the patient was 
still alive in 12 months, compared to the GPs who would 
not be surprised if the patient was still alive in 12 months. 
Table 2. Answer combinations to SQ1+SQ2 and mean RADIANT scores per case vignette.
Abbreviations: GP: general practitioner, SQ1: first surprise question, SQ2: second surprise question, RADIANT score: RADboud 
ANTicipatory score, a scoring method to quantify the open text content of palliative care plans made by GPs.
No (n=8)
No (n=8)
No (n=8)
No (n=8)
No+Yes (n=2)
No+No (n=2)
Yes+No (n=1)
No+Yes (n=5)
No+No (n=0)
Yes+No (n=0)
No+Yes (n=0)
No+No (n=4)
Yes+No (n=1)
No+Yes (n=2)
No+No (n=1)
Yes+No (n=2)
No+Yes (n=1)
No+No (n=3)
Yes+No (n=1)
No+Yes (n=5)
No+No (n=0)
Yes+No (n=0)
No+Yes (n=1)
No+No (n=3)
Yes+No (n=1)
No+Yes (n=1)
No+No (n=4)
Yes+No (n=0)
3.63
4.0
3.3
3.4
3.5
1.0
0
3.0
-
-
-
2.0
3.0
3.0
2.0
3.0
4.0
3.7
2.0
4.0
-
-
3.0
2.7
2.0
5.0
1.8
-
Vignette  A
Vignette B
Vignette C
Vignette D
Group 3 (n=5)Group 2 (n=8)
Answer 
SQ1
Q1+SQ2 Answers
SQ1+SQ2
RADIANT 
score
RADIANT 
score
RADIANT 
score
Group 4 (n=5)
3.3 Secondary Outcome Measures
RADIANT scores were highest in group 2 (SQ1) and lowest 
in group 1 (no SQs). When comparing the RADIANT scores 
for the different vignettes, vignette B (terminal oncology 
case) scored higher than the other vignettes. Overall, 
the highest RADIANT score was found for vignette B in 
groups 2 (SQ1) and 4 (SQ1, SQ2 and PS). In all groups, 
RADIANT scores were higher for plans written in Slovenian 
compared to those written in English (Table 3).
10.2478/sjph-2018-0008 Zdr Varst. 2018;57(2):55-64
59
The highest proportion of anticipatory care plans (40–
80%) was made by GPs in group 4 (SQ1, SQ2 and PS), and 
the lowest (25–50%) in group 2 (SQ1) (Table 4). When 
comparing the proportions of anticipatory care in the 
different vignettes, the patient B (terminal oncology 
patient) scored highest (40–80%), and the patient C (frail 
elderly patient with dementia) scored lowest (20–40%).
Table 3.
Table 4.
Mean RADIANT scores* per case vignette in groups 1-4.
Proportions of reactive and anticipatory palliative care plans.
*RADIANT score: RADboudANTicipatory score, a scoring method to quantify the open text content of palliative care plans made by GPs.
Abbreviations:  A: All participants in this study group; E: Participants in this study group that completed the survey in English (n=15); S: 
Participants in this study group that completed the survey in Slovenian (n=11).
Shows the proportions of care plans that contain reactive and anticipatory aspects for each vignette per study group;  
Abbreviations: R: reactive care; A: anticipatory care
1.9
3.6
1.8
3.4
2.7
88%
100%
80%
100%
92%
100%
100%
100%
100%
100%
88%
100%
100%
100%
96%
63%
100%
80%
80%
81%
84%
100%
90%
95%
-
38%
50%
80%
40%
50%
50%
50%
40%
80%
54%
25%
25%
20%
40%
27%
63%
38%
40%
40%
46%
44%
41%
45%
50%
-
2.0
3.3
2.2
2.6
2.5
2.2
3.6
2.5
3.1
-
3.3
4.0
3.0
4.0
3.6
1.5
3.4
2.8
2.4
2.5
1.7 (n=3)
3.5 (n=4)
2.0 (n=4)
2.8 (n=4)
-
2.5 (n=5)
3.6 (n=4)
4.3 (n=1)
4.3 (n=1)
-
Group 1 (n=8)
Group 2 (n=8)
Group 3 (n=5)
Group 4 (n=5)
Total (n=26)
Group 1 (n=8)
Group 2 (n=8)
Group 3 (n=5)
Group 4 (n=5)
Total (n=26)
Vignette A
Vignette A
R RR R RA AA A A
Vignette C
Vignette C
A
Total
Total
Vignette B
Vignette B
Vignette D
Vignette D
E S
The somatic dimension was most often included in the 
PC plans in all study groups (75%-95%) and all vignettes 
(65-100%), while the social/financial dimension was least 
mentioned within the different study groups (5-25%) and 
in vignettes B (terminal oncology patient) (19%) and D 
(advanced stage, but not yet terminal oncology patient) 
(12%). The existential/psychological dimension was least 
explored in vignettes A (organ failure patient) (4%) and 
C (frailty elderly with dementia) (8%). Group 1 (no SQs) 
shows the highest proportions of PC plans including all 
four aspects of multidimensional PC (9%), while none of 
the PC plans in group 4 (SQ1, SQ2 and PS) included all four 
aspects (Table 5). 
10.2478/sjph-2018-0008 Zdr Varst. 2018;57(2):55-64
60
3.4 Opinions 
GPs were triggered to start PC in case of a terminal or 
incurable disease, like cancer or dementia, and symptoms, 
like pain, dyspnoea, weight loss and immobility. The second 
trigger were social aspects like ‘loss of independence,’ 
‘absence of the next of kin,’ ‘powerlessness of relatives’ 
or ‘lack of home care and support.’
Seventeen of the eighteen GPs who were asked SQ1 and 
all ten GPs who were asked the combined SQ found the 
tools helpful. However, four GPs had some concerns about 
the usefulness of either SQ1 or the combined SQs in daily 
practice (Figure 4). All five GPs in group 4 (SQ1, SQ2, 
PS) considered the PS to be a helpful tool for planning 
multidimensional PC. 
Table 5. Multidimensional care.
Showing the proportion of care plans that include each of the four dimensions of palliative care for each study group and for each 
vignette separately and the proportion of care plans in each of the four study groups that include aspects of all four domains. * ADL: 
activities of daily living
84%
94%
75%
95%
89%
100%
96%
65%
9%
25%
5%
10%
8%
19%
15%
12%
38%
59%
25%
55%
54%
54%
65%
8%
16%
31%
20%
15%
4%
35%
8%
35%
9%
6%
5%
0%
Group 1
Group 2
Group 3
Group 4
Vignette A
Vignette B
Vignette C
Vignette D
Somatic Care giving /ADL* All domainsSocial / financial Existential / 
psychological
Figure 4. Statements about the usefulness of the first and second surprise questions.
10.2478/sjph-2018-0008 Zdr Varst. 2018;57(2):55-64
61
4 DISCUSSION
In this pilot study, GPs were invited to plan care based on 
patient cases. GPs who were asked SQ1 and SQ2 before 
making the care plans, planned the most elaborate care 
for patients for whom they would not be surprised if they 
died within 12 months (the answer to SQ1 is ‘no’) and 
would be surprised if they were still alive after 12 months 
(the answer to SQ2 is ‘yes’). This is in concordance with 
our hypothesis that answering SQ1 with ‘no’ and SQ2 with 
‘yes’ would lead to more elaborate PC than other answer 
combinations.
4.1 Disease Trajectories
In this study, the terminal oncology patient was most 
often identified as being likely to die within a year 
and, therefore, received the most elaborate care. The 
frail elderly patient suffering from dementia was least 
expected to die within 12 months and was allocated 
less anticipatory and multidimensional care. This is in 
concordance with a systematic review by Gardiner et al. 
that mentions the delayed recognition of the palliative 
transition in non-cancer patients (11). Evans et al. 
found that organ failure and old-age/dementia patients 
received PC less frequently than cancer patients. They 
also found that old-age/dementia patients, the group of 
patients most likely to lose decision-making capacity, had 
the least end-of-life discussions and anticipatory care 
planning (10). 
4.2 PC in Slovenia
A study with the same methodology was recently 
performed among Dutch GPs. The mean RADIANT scores in 
this Dutch study ranged from 4.9 to 8.9 and are noticeably 
higher than the Slovenian mean scores ranging from 2.2 
to 3.6 (21). 
The mean RADIANT scores were higher for the care plans 
written in Slovenian than for the plans written in English. 
It is likely that some of the subtler treatment descriptions 
and nuances in the care plans were lost in translation 
or misinterpreted due to different meanings of words in 
different languages.
The differences in RADIANT scores between the Dutch 
and Slovenian studies lie within the anticipatory and 
psychosocial aspects of the care plans. Dutch GPs 
discussed patients’ aspects of quality of life, goals, 
and preferences more frequently than Slovenian GPs. 
In addition, Slovenian GPs scored fewer points on the 
social/financial and existential/psychological dimensions 
of multidisciplinary care. In this Slovenian study, 
treatment limitations, preferences for end-of-life care, 
dying scenarios and preferred places of death were 
never mentioned. This might be because Slovenian GPs 
did not consider discussing these topics as treatment 
and, therefore, did not include them in the care plan. 
Another possibility is that Slovenian GPs are less prone 
to discuss these topics due to differences between 
Dutch and Slovenian laws regarding matters as palliative 
sedation, euthanasia and advance directives. There 
are also cultural differences regarding health care, in 
general, and PC, in particular. In 2002, Lunder and Cerv 
wrote the following about PC in Slovenia: There has been 
long subjugation of the country to another’s rule. In the 
period of socialism, death was pushed into the sphere of 
the private, and the Church. There was no interest in the 
development of public institutions, like palliative care 
wards in hospitals or hospices (25). Ten years later, a study 
regarding psychosocial care in cancer patients concluded 
that the need for further development of psychosocial 
care in Slovenia is still underestimated, but first attempts 
are being made to fill this gap (26).
There is much to gain in terms of PC education since this 
subject takes up only 8 hours in the general curriculum of 
the University of Ljubljana, and 15 hours for the University 
of Maribor (27). Another point of attention is the content 
of PC education programs. Findings from an international 
review show that concepts of pain management are being 
well addressed, but current undergraduate curricula may 
not adequately explore issues of broader symptom control, 
and psychosocial and spiritual aspects of care (28). The 
need and wish for these educational initiatives is also 
mentioned by Chang et al. (29). Furthermore, they are 
reflected in the self-assessed scores for PC skills (6.5 out 
of 10), interest in PC (8.3 out of 10), and the proportion of 
GPs who indicated to have plans to improve their PC skills 
(90%). Unfortunately, the number of PC experts willing to 
work as PC providers or teachers is insufficient according 
to the EAPC (27). Nonetheless, in Slovenia, PC education 
initiatives have been developed in both undergraduate 
and postgraduate programs. Several courses are organized 
to provide doctors and other healthcare professionals 
with special knowledge and skills in PC (30). 
4.3 Opinions 
The participants mentioned multiple physical and social 
aspects that trigger them to initiate PC. Similar aspects 
were mentioned by Dutch and British GPs in two separate 
studies (1, 17). The SQs were considered to be helpful 
tools for the identification of patients in need of PC. 
Concerns about the usefulness of the SQs included the 
difficulty of the prediction of prognosis, especially in non-
cancer patients, and uncertainty about how to interpret 
the answers to the SQs. This uncertainty regarding 
interpretation is apparent in other studies as well. The SQ 
is often used as a prognostication tool to predict 1-year 
mortality while it was developed as a tool to identify 
patients with PC needs (15-17). The last concern was 
10.2478/sjph-2018-0008 Zdr Varst. 2018;57(2):55-64
62
regarding the communication with the patient once the 
GP has considered the SQs. Communication has been 
mentioned before as a barrier for the early initiation 
of PC (8, 9, 31). The positive opinions regarding the PS 
are mirrored by recent research by Thoonsen et al., 
in which GPs stated that this PS helped them consider 
actual and possible future problems, needs and scenarios 
regarding all dimensions of PC (32). Surprisingly, this 
current study shows no effect of the use of the PS on the 
multidimensionality of the care plans. In fact, group 4 was 
the only group in which none of the care plans mentioned 
all four dimensions of PC. 
4.4 Strengths and Limitations
The strength of this study lies in the fact that it combines 
the original SQ with a second SQ and a PS. This approach 
does not only help GPs to identify patients who are at high 
risk to deteriorate and die, but also triggers them to start 
multidisciplinary and anticipatory PC. 
Unfortunately, due to the small number of participants, 
the results of this pilot study could not be subjected 
to significance testing, so any of the differences found 
might be due to chance. Another limitation is that the 
vignettes and score form were developed for use among 
Dutch GPs. This might explain the low RADIANT scores, 
low response rate and low number of GPs who actually 
completed the survey. The length of the survey also 
seemed to have a negative influence on participation, 
since less surveys were completed in groups 3 and 4, in 
which the survey contained more questions than in groups 
1 and 2. The timing of the study was not ideal either, since 
the invitations and surveys were sent in July and August, 
when many GPs were on holidays. 
5 CONCLUSION
This was one of the first studies to investigate the use of 
the combined SQs. The results of this pilot study seem 
promising, but further research is needed regarding 
the usefulness in daily practice. Furthermore, it seems 
worthwhile to continue exploring how GPs can be 
triggered to identify patients in need of PC, and to start 
multidisciplinary and anticipatory care. More attention 
could be given to the psychosocial aspects of care and 
to the discussion of patients’ goals and preferences for 
end-of-life care. In the future, PC should become more 
generally available for non-cancer patients. Further 
development of PC education programs and national 
guidelines could be the first step towards reaching these 
goals in Slovenia. 
CONFLICTS OF INTEREST
The authors declare that no conflicts of interest exist.
FUNDING
No funding was required.
ETHICAL APPROVAL
Received from the Slovene Medical Ethics Committee on 
14-06-2016, consent number KME 126/06/16.
REFERENCES
1. Claessen SJ, Francke AL, Engels Y, Deliens L. How do GPs identify a 
need for palliative care in their patients? An interview study. BMC 
Fam Pract. 2013;14:42. doi: 10.1186/1471-2296-14-42. 
2. Makivić I, Kersnik J, Klemenc-Ketiš Z. The role of the psychosocial 
dimension in the improvement of quality of care: a systematic 
review. Zdr Varst. 2015;55:86-95. doi: 10.1515/sjph-2016-0004.
3. Abarshi E, Onwuteaka-Philipsen B, Donker G, Echteld M, Van den 
Block L, Deliens L. General practitioner awareness of preferred place 
of death and correlates of dying in a preferred place: a nationwide 
mortality follow-back study in the Netherlands. J Pain Symptom 
Manage. 2009;38:568-77. doi: 10.1016/j.jpainsymman.2008.12.007.
4. Gomes B, Calanzani N, Curiale V, McCrone P, Higginson IJ. 
Effectiveness and costeffectiveness of home palliative care services 
for adults with advanced illness and their caregivers. Cochrane 
Database Syst Rev. 2013;6:CD007760. doi: 10.1002/14651858.
CD007760.
5. Švab I, Kravos A, Vidmar G. Factors influencing home visits in 
Slovenian general practice. Fam Pract. 2003;20:58-60.
6. European Association for Palliative Care. Promoting palliative care 
in the community: producing a toolkit to improve and develop 
primary palliative care in different countries internationally. doi: 
10.1177/0269216314522318. Accessed Juny 6th, 2016 at: http://
www.eapcnet.eu/LinkClick.aspx?fileticket=PXlXlRoSrXU%3D. 
7. Beernaert K, Deliens L, De Vleminck A, Devroey D, Pardon K, Van Den 
Block L, et al. Early identification of palliative care needs by family 
physicians: a qualitative study of barriers and facilitators from the 
perspective of family physicians, community nurses, and patients. 
Palliat Med. 2014;28:480-90. doi: 10.1191/0269216305pm937oa.
8. Groot MM, Vernooij-Dassen MJFJ, Crul BJP, Grol RP. General 
practitioners (GPs) and palliative care: perceived tasks and 
barriers in daily practice. Palliat Med. 2005;19:111-8. doi: 
10.1177/0269216314526271.
9. Evans N, Pasman HR, Donker GA, Deliens L, Van den Block L, 
Onwuteaka- Philipsen B. End-of-life care in general practice: a cross-
sectional, retrospective survey of ‘cancer’, ‘organ failure’ and ‘old-
age/dementia’ patients. Palliat Med. 2014;28:965-75. doi: 10.1136/
bmjspcare-2010-000001.
10. Gardiner C, Ingleton C, Gott M, Ryan T. Exploring the transition 
from curative care to palliative care: a systematic review of the 
literature. BMJ Support Palliat Care. 2011;1:56-63. doi: 10.1200/
JCO.2008.17.7568.
11. Thoonsen B, Engels Y, van Rijswijk E, Verhagen S, van Weel C, Groot 
M, et al. Early identification of palliative care patients in general 
practice: development of RADboud indicators for PAlliative Care 
Needs (RADPAC). Br J Gen Pract. 2012;62:625-31. doi: 10.1001/
jama.2009.1198.
10.2478/sjph-2018-0008 Zdr Varst. 2018;57(2):55-64
63
Appendix 1: vignettes
Vignette A
Mrs. A., 83 years old, is widowed and lives independently 
in a detached house on the outskirts of the village. She 
and her husband used to run several shops in the centre of 
the nearest city. She has six children, who are all closely 
involved. She enjoys life, and particularly the company of 
her children and grandchildren. Her cognitive functions 
are still excellent, but she has several relevant somatic 
problems, the most important of which are:
• COPD Gold III-IV. She still enjoys several cigarettes 
per day. 
• Presbycusis, for which she wears bilateral hearing 
aids.
• Diabetes type 2.
• Kidney failure (MDRD <30).
12. Hlebec V, Srakar A, Majcen B. Determinants of unmet needs 
among Slovenian old population. Zdr Varst. 2016;55(1):78-85. doi: 
10.1177/0269216314545006.
13. Follwell M, Burman D, Le LW, Wakimoto K, Seccareccia D, Bryson J, 
et al. Phase II study of an outpatient palliative care intervention in 
patients with metastatic cancer. J ClinOncol. 2009;27:206-13. doi: 
10.3399/bjgp12X654597.
14. Bakitas M, Lyons KD, Hegel MT, Balan S, Brokaw FC, Seville J, et 
al. Effects of a palliative care intervention on clinical outcomes in 
patients with advanced cancer: the Project ENABLE II randomized 
controlled trial. JAMA. 2009;302:741-9. doi: 10.1089/jpm.2010.0018.
15. Moss AH, Lunney JR, Culp S, Auber M, Kurian S, Rogers J, et al. 
Prognostic significance of the “surprise” question in cancer patients. 
J Palliat Med. 2010;13:837-40. doi: 10.3747/pdi.2011.00204.
16. Moroni M, Zocchi D, Bolognesi D, Abernethy A, Rondelli R, Savorani 
G, et al. The ‘surprise’ question in advanced cancer patients: 
a prospective study among general practitioners. Palliat Med. 
2014;28:959-64. doi: 10.1177/0269216314526273.
17. Elliott M, Nicholson C. A qualitative study exploring use of the 
surprise question in the care of older people: perceptions of general 
practitioners and challenges for practice. BMJ Support Palliat Care. 
2017;7:32-8. doi: 10.1136/bmjspcare-2014-000679.
18. Downar J, Goldman R, Pinto R, Englesakis M, Adhikari NK. The 
“surprise question” for predicting death in seriously ill patients: a 
systematic review and meta-analysis. CMAJ. 2017;189(13):E484-93. 
doi: 10.1186/1471-2296-12-123.
19. White N, Kupeli N, Vickerstaff V, Stone P. How accurate is the ‘Surprise 
Question’ at identifying patients at the end of life? A systematic 
review and meta-analysis. BMC Med. 2017;15(1):139. 
20. Thoonsen B, Groot M, Engels Y, Prins J, Verhagen S, Galesloot C, et 
al. Early identification of and proactive palliative care for patients in 
general practice, incentive and methods of a randomized controlled 
trial. BMC Fam Pract. 2011;12:123.
21. Weijers F. Does adding the Surprise Questions to case vignettes 
help GPs to increase the thoroughness of palliative care planning? 
Results of a pilot RCT. Unpublished manuscript, Radboud University, 
Nijmegen, The Netherlands, 2016.
22. World Health Organization Definition of Palliative Care. Accessed 
Juny 10th, 2016 at: http://www.who.int/cancer/palliative/
definition/en/.
23. Pallialine: general principles of palliative care. Accessed July 14th, 
2016 at: http://pallialine.nl/algemene-principes-van-palliatieve-
zorg.
24. Information for patients about end-of-life decisions and treatment 
limitations. Accessed July 14th, 2016 at: http://www.thuisarts.nl/
levenseinde.
25. Lunder U, Cerv B. Slovenia: status of palliative care and pain relief. J 
Pain Symptom Manage. 2002;24:233-5. doi: 10.1002/pon.3154.
26. Grassi L, Watson M. Psychosocial care in cancer: an overview of 
psychosocial programmes and national cancer plans of countries 
within the International Federation of Psycho-Oncology Societies. 
Psychooncology. 2012;21:1027-33.
27. Centeno C, Lynch T, Donea O, Rocafort J, Clark D. EAPC atlas of 
palliative care in Europe 2013. Milan: EAPC Press, 2013.
28. Fitzpatrick D, Heah R, Patten S, Ward H. Palliative care in 
undergraduate medical education - how far have we come? 
Am J Hosp Palliat Care. 2017;34:762-73. doi: 10.1111/j.1440-
172X.2008.01723.x.
29. Chang E, Daly J, Johnson A, Harrison K, Easterbrook S, Bidewell J, et 
al. Challenges for professional care of advanced dementia. Int J Nurs 
Pract. 2009;15:41-7. doi: 10.1186/s12875-015-0342-6.
30. Albreht T, Pribaković Brinovec R, Josar D, Poldrugovac M, Kostnapfel 
T, Zaletel M, et al. Slovenia: health system review. Health Syst 
Transit. 2016;18:1-207. doi: 10.1136/bmjspcare-2015-001031.
31. Thoonsen B, Vissers K, Verhagen S, Prins J, Bor H, van Weel C, et al. 
Training general practitioners in early identification and anticipatory 
palliative care planning: a randomized controlled trial. BMC Fam 
Pract. 2015;16:126. doi: 10.1186/s12875-015-0342-6.
32. Thoonsen B, Gerritzen SH, Vissers KC, Verhagen S, van Weel C, 
Groot M, et al. Training general practitioners contributes to the 
identification of palliative patients and to multidimensional care 
provision: secondary outcomes of an RCT. BMJ Support Palliat Care. 
2016; Epub ahead of print. doi: 10.1136/bmjspcare-2015-001031. 
 
• Anaemia.
• In 2011, she suffered a severe myocardial infarction, 
for which she underwent an emergency PTCA and 
coronary stent placement. Unfortunately, she 
developed severe heart failure (NYHA classification 
3–4).
Her main complaints are fatigue and some exertional 
dyspnoea. Her exercise capacity is clearly decreasing and 
walking longer distances within her house is sometimes 
challenging. In the past year, she has experienced several 
acute exacerbations of both heart failure and COPD, often 
combined. She regularly asks you about treatment options 
regarding her fatigue since she still very much enjoys life 
and does not want to say farewell to her children yet. 
Vignette B
56-year-old Mr. W. is married and lives with his wife in an 
apartment on the edge of the forest. His wife is 52 years 
of age and very healthy. They have two daughters and five 
grandchildren. Both daughters are involved and live in the 
same area.
Mr W. is a manager at the university. He is rarely ill, but 
in the last few months, he has been having fluctuating, 
but sometimes severe pain of his upper abdomen. He also 
suffers from general malaise and an overall decline in his 
physical abilities. His condition was difficult to diagnose 
at first, but eventually a metastatic pancreatic tumour 
was found. Currently, he is suffering severe pain and he 
has lost several kilograms of weight. A coeliac plexus 
blockade has been planned. He is only moderately fit, but 
calm and resigned. 
Vignette C
Mrs. C. is a 91-year old childless widow. She lives alone in 
a luxurious apartment, where additional care is provided. 
She has an 85-year-old sister in law, who cares for her. 
Mrs. C. has been experiencing increasing problems in 
her daily life. She hardly leaves her house and tends to 
fail performing certain complex tasks. Her (short-term) 
memory seems to be intact. She is, however, increasingly 
disoriented in time and place (orientation in person is 
intact). A year and a half ago she was diagnosed with 
dementia by a geriatrician. 
Several years ago, she had a heart attack, for which 
she was hospitalized and treated conservatively with 
medication. Next, she developed heart failure, which is 
currently stable. She also has atrial fibrillation, for which 
she takes oral anticoagulants. 
She developed squamous cell carcinoma in her face several 
times. Recently, one of those carcinomas, situated at the 
right side of her mount, was surgically removed. Because 
of postoperative complications, she had to undergo a 
repeat surgery. This resulted in permanent dysfunction of 
the right side of her mouth causing eating difficulties and 
several kilograms of weight loss in the past months. 
Finally, she suffers from bilateral coxarthrosis, which 
causes pain every now and then. 
Lately, Mrs. C. has fallen regularly. Since her last fall, she 
has been immobilized due to severe lower back pain. She 
spends most of the day either dozing in her chair or lying 
in bed. Two years ago, she went through an episode during 
which she experienced the same problems, caused, at that 
time, by osteoporotic vertebral infraction. She recovered 
spontaneously from this previous episode in six months. 
Vignette D
69-year-old Mr. T. is married and lives with his wife in a 
single-family home. He is quite healthy and hardly ever 
ill.
After a period of vague abdominal complaints, he was 
referred to an internist, who diagnosed him with colon 
cancer with hepatogenous and pulmonary metastasis. At 
first, Mr. T. was very emotional about this news, but after 
a while, he regained his calm. 
Mr. T. would like to receive life-prolonging treatment. He 
is very fit and hardly experiences any complaints now. He 
has an appointment with a medical oncologist to discuss 
the possible options. He is very motivated to continue 
treatment.
10.2478/sjph-2018-0008 Zdr Varst. 2018;57(2):55-64
64