Planning, Risk Assessment and Communication
Transfers in palliative and end-of-life care must be carefully planned, risk-assessed, and communicated to ensure the person’s safety, comfort, and dignity.
- Harm during transfer: Pain, discomfort, or confusion, especially for people with dementia or delirium.
- Inappropriate care: Receiving care unsuitable to the person’s needs in the new environment.
- Unprepared settings: The receiving service may not be able to provide the required care.
- Lack of communication: Family, friends, or substitute decision-makers are not informed of the transfer.
- Delays returning to the facility: Long waits for transport can cause stress and discomfort.
- Build strong connections with nearby hospitals, palliative care teams, and other services. Ensure staff know key contacts.
- Develop clear transfer of care policies, including roles, responsibilities, and step-by-step procedures.
- Communicate openly with the person and those involved in their care about transfer decisions.
- Regularly review feedback from receiving services to identify areas for improvement.
- Reflect on transfer processes and outcomes to improve future planning.
- Seek input from substitute decision-makers, family, and support networks.
When moving an older person from one place to another, good planning is important. Planning should happen before a planned transfer and as soon as possible in an emergency.
Aged care providers should have clear guidelines for moving people in and out of a care home. These guidelines should include:
- who is responsible for making decisions about transfers
- the steps to follow during a transfer - including verbal handover and what documentation to send
- the roles and responsibilities of staff.
It is important to consider the needs of different residents, including their health, culture, and personal preferences.
Key elements of good planning include:
Strong relationships and linkages with local services (such as hospitals, specialist palliative care services, etc.)
Good relationships with hospitals and specialist care teams help make transfers smoother and ensure important information is shared. Link with and plan ahead if cultural support, interpreters, or translators are needed, they can improve the experience for the resident and their family.
Do a risk assessment
Assess and address any safety or wellbeing concerns in the new environment before, during, and after the transfer. (see box).
Estimating the date of transfer
Record the expected transfer date and share it with the care team. Update it if the person’s condition changes or the receiving service is not ready. Keep the older person and family informed to reduce anxiety about the transfer.
Allocate key people to support the transfer
Make sure the roles and responsibilities are clear for:
- a person to help the resident (and their family or support network) plan for the transfer
- a health professional to ensure care teams work together and share information
- a key contact to communicate with the receiving or discharging service.
Risk assessment considerations
- Is the person approaching in the end-of-life phase or close to it?
- What is the risk of the person passing away during transport?
- Will the new environment be safe and comfortable for the person?
- If the transfer is to the person’s or their family’s private home:
- Are the family or friends well-prepared and informed?
- Is there enough support for medical and personal care?
- Will there be 24-hour care?
- Do the family or friends have emotional support?
- What actions or information need to be shared, to manage risks?
The provider will decide which medications are appropriate for the person returning home or to the care home. These may include pain relief, sedation, or other medications needed at the end of life.
Creating a transfer plan
The plan should be informed by the person, their family and those involved in the resident’s care and include:
- relevant information from the risk assessment
- the planned date and time of transfer
- the transport arrangements for the transfer
- any information or plans relevant to:
- advance care planning
- behaviours requiring support
- communication needs
- cultural, spiritual and wellbeing needs (e.g. need for a cultural support person)
- medications and how these will be transferred
- any personal items (including communication aids and equipment) to be transferred and how these will be moved
- how continuity of care will be ensured, including handover information (see Transfers Continuity of Care Between Settings).
Clear communication
When older people are transferred between care settings, they (and if relevant, their substitute decision maker) should know:
- what will happen during the transfer
- how to stay in touch with family and support services
- what to expect in the new care setting
- how to connect with spiritual/pastoral/cultural support services in the new setting
- if and when they will return.
Reassessing the person when they return home
It is good practice to reassess a person’s end-of-life care needs and wishes when they return home or to residential aged care. The experience they’ve had during hospitalisation and/or as a result of the transfer may have changed how they want to be cared for. Reassessing helps make sure any extra support is given if needed and that the care plan is still right for them.