Background In Limburg (province in the South East of The Netherlands), in May 2015 a new ACP pathway will be implemented into four primary care facilities and four ambulatory care wards of Orbis Medical Centre. Its aim is the early identification of (oncological and chronically ill) patients who will probably die within one year, discuss patients in a multidisciplinary setting, and to provide them with a pro-active care plan. This should result into higher experienced quality of care, of death and dying and into less unnecessary health care usage.

Aim To gain insight into both the effects and the (implementation) process, by measuring several indicators: place of preferred death, quality of death and dying, experiences with care, burden of care as experienced by spouses, profiles of health care consumption (admissions, crisis situations, replacements). Additionally, we will survey facilitators and barriers to the implementation.

Methods The pathway will continuously be evaluated during the next 2,5 years. Some indicators will be measured in both the intervention group and a control-group; other are only measured cross-sectionally. Clinical assessment of patients will be done during the intake. We will conduct semi-structured interviews with health care professionals and spouses. We will use patient data from physician and hospital information systems to reconstruct health care usage.

Results We expect to include 250 patients yearly. Preliminary results can be presented in Sep 2015.

Discussion We would like to discuss the study design, indicators, questionnaires, and data collection methods. Second, we would like to reflect on the pathway (identification, assessment, follow-up, multidisciplinary interaction).