Advance care planning is necessary for patients with chronic disease who are in their last year of life. To timely start advance care planning, it is important to identify those patients. The ‘surprise question’ – Would I be surprise if this patient died in the next 12 months? – is recommended, but it has a moderate sensitivity and low positive predictive value in the prediction of 1-year mortality.
Using predictors as identified in literature, clinical models to predict 1-year mortality in patients with cancer and patients with chronic obstructive disease will be developed. An e-learning to support physicians in their communication with patients who are in their last year of life, will also be developed.