Planning for a home death

• What has the patient said about their wish to stay at home to die?
• Do those who live with the patient know about and share that wish?
• Has the plan been discussed within the family?
• Is it possible to determine the patient's prognosis, in order to help the family plan ahead and marshal their resources?
• What is the back-up plan if either the patient or the family find it difficult?

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You may need to consider:

• Young children, others with care needs in the household
• Practical, hands on availability for round the clock care
• Specific services that could support families caring for someone who is dying at home, (eg, night nursing services or volunteers - the local palliative care service can advise)
• Written plan that it is realistic, and understood by all involved

• Will the patient be able to be cared for safely and comfortably in the home?
• How much nursing support is available? Specifically, how many visits can the patient have?
• Are there complex nursing needs that will be difficult to manage at home eg, difficult wounds, fistulas, spinal analgesia, etc
• Can practical rearrangements that t make caring easier or safer - eg, moving a patient's bed to a different room

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You may need to consider:

• Referral to home nursing or palliative care nursing services, and ask them to teach the family about how to provide care safely
• Equipment that may be needed to nurse a bed-bound patient: eg, hospital bed, mobility aids, commodes and other personal care equipment, wheelchair, pressure mattresses
• Palliative care referral for an occupational therapy and/or physiotherapy assessment to advise on and organise equipment
• Option of an in-dwelling catheter to reduce the burden on both patient and family in the terminal phase

• Review long-term medications - cease any that no longer contribute to the patient’s comfort
• Discuss with the family how the patient's symptoms will be reviewed and managed particularly whether home nurses will report to the GP, how often GP visits will occur, what the palliative care service will do, and arrangements for providing prescriptions.
• Plan for predictable, common symptoms that occur at the end-of-life:
  • Agitation
    
  • Anxiety
    
  • Delirium
    
  • Dyspnoea
    
  • Nausea
    
  • Pain
    
  • Terminal secretions
• Ensure emergency medications are available in the house for when they are needed. This is best done well in advance as deterioration can be unpredictable. Remember - dying patients cannot take oral medications
  
• Ensure family is equipped to manage medications including breakthrough doses.
  
• Check that medications are available at a community pharmacy, and that the caregivers have an adequate supply to get through after hours and weekends in particular

You may need to consider:

• Whether a plan is needed for high-risk problems such as bleeding risk or bowel/airway obstruction

• Are the carers fully prepared for the fact that the dying person will be dependent and bed bound?
• Do the carers need information about eating and drinking in the palliative care situation eg loss of appetite, swallowing issues
• Do the carers need information about physical changes that occur as a person is dying
• Do the carers know what to do after the death?
• Ensure that the family has access to twenty four hour phone advice about symptoms or changes in the patient's condition, and that everyone providing care knows who to contact
• Do the caregivers need information about what to do after the patient dies? eg, encourage them to think about choosing a funeral director
• Reassure them that there is no urgency to ring anyone after the patient dies
• Ensure that they know which doctor has agreed to certify death, and the arrangements for contacting them

You may need to consider:

• If the family has access to twenty four hour phone advice about symptoms or changes in the patient's condition, and that everyone providing care knows who to contact