Transfers
This section aims to support health professionals and care staff working with older people to navigate transfers of residents receiving palliative care between different care settings and to identify and manage associated risks.
There is also a factsheet for residents, their families and friends.
Key messages
- People in aged care may need or want to transfer between care settings during the palliative phase.
- The person must give consent, or if they lack capacity, their substitute decision-maker must decide.
- Before a transfer, staff should:
- provide clear information to support decision-making
- respect the person’s wishes, including those in Advance Care Plan documentation
- recognise the person’s right to refuse transfer or treatment, even if life-sustaining
- avoid unnecessary or unplanned transfers during the palliative phase.
- Safe and smooth transfers happen when there is good planning, a proper risk assessment, and clear communication. This includes involving the person, their family (with consent), their substitute decision-maker, and care providers.
- Continuity of care means making sure a person’s care is well-organised and consistent when they move between care settings. This requires sharing important information, so their needs and preferences are always respected.