Going home from hospital for end of life care

We need to act quickly to organise this discharge and will make sure you and your family / carer are included in all discussions and plans.

This may be a worrying time for all of you. It is important for us to make sure you fully understand what is involved in the transfer home.

The hospital and community team will work together to organise your discharge. You will be allocated a Health Case Manager who will discuss your care and support needs to ensure you receive the appropriate services.

Things that we will discuss with you are:

• your plans and wishes;
• who will support you at home;
• care available in the community on discharge;
• equipment that might be needed;
• medicines that might be prescribed;
• what may happen if your condition changes suddenly; and
• NHS Continuing Healthcare Fast Track.

Please speak to the team on the ward looking after you if you or your family / carers have any questions, they are here to support you at this time.

ReSPECT

As we plan your discharge together, we may discuss whether or not readmission to hospital for treatment would help you and if you would want to be readmitted. Recommendations about care and treatment, including hospital readmission, will be recorded on a form called ReSPECT, along with your wishes and preferences. This form is given to you to keep in your house and the information is recorded on the computer system for community professionals involved in your care (such as Neighbourhood Team, GP and the hospital team).

These recommendations can help the people looking after you make treatment decisions if you are too unwell to say what your wishes are.

Equipment

Equipment might be needed at home, e.g. hospital bed, pressure relieving mattress, prescription items and oxygen. If needed, staff will discuss this with you and your family / carer. Space may be needed for essential equipment / oxygen, this may involve moving / storing furniture. The equipment will have to be delivered and someone will need to be there to accept the delivery.

Medications

Medicine that is not helpful at this time may be stopped and new medicines prescribed. If needed, the hospital team will prescribe these medicines to go home with for symptoms such as breathlessness, pain, agitation or sickness. These medications can have side-effects, which the ward will explain to you. Please ask the ward if you have any questions. Injectable medicines will be given by a registered nurse in the community when needed, at the right time and just enough for comfort. You may also currently be receiving medication through a syringe pump. The ward will make the community nurses aware of your needs.

Transport

A dedicated Palliative Care Ambulance Service may be able to respond at short notice to transfer you to your preferred place of care. If unavailable, other patient transport will be used as an alternative. Your family / carer will be able to go in the Palliative Care Ambulance with you during the journey home if they wish to do so.

Once home, if you do not understand anything, please talk to your GP or Community Neighbourhood Team.

Useful contact details
(to be completed on discharge by ward nurse)

Your GP and Community Neighbourhood Team details will given to you by your ward nurse

Community Neighbourhood Team out of hours (Leeds only)
Tel. 0300 003 0045

For out of hours advice, you can also contact NHS 111 directly.

You wish to make a list of any questions you may wish to ask the doctors / nurses or the Health Case Manager.

We hope you have found this leaflet helpful at this difficult time.

If you would like to read this leaflet in another language, please visit: https://www.leedsth.nhs.uk/patients/resources.

This is only available in non-English languages online – printed copies are in English.