Overview

People may need to move between care settings during the palliative phase as their needs and preferences change. Transfers may include:

• hospital for urgent or specialised care
• hospice for end-of-life support
• a family home for personal care
• returning to residential care from the community.

Key outcomes for transfers

• Involving the person, their family (with consent), or their substitute decision-maker in decisions.
• Prioritising comfort, quality of life, and minimising stress.
• Ensuring clear communication between transferring and receiving teams.
• Providing safe, high-quality care that respects the person’s needs and choices.
• Reducing unnecessary disruptions to care, medications, and treatment.

Managing transfers can be complex, with legal, clinical, and communication risks. This resource doesn’t cover all risks, but it may help aged care staff identify and manage key risks to ensure person-centred, high-quality care as part of risk-based thinking.

The Final Report of the Royal Commission into Aged Care Quality and Safety (2021) highlighted concerns about care transitions. It recommended better coordination between aged care, health, and palliative care services, clear documentation of care preferences, and staff training. It also stressed the importance of involving specialist palliative care when needed to reduce unnecessary transfers.