Home visits and after-hours arrangements in palliative care

After-hours care and advice may be provided by various healthcare professionals (depending on local healthcare services), including general practitioners (GPs), specialist physicians, locum doctors, specialist palliative care or community nursing services, and paramedics. Palliative care specialists provide support for the management of complex problems faced by patients with palliative care needs (and their doctors). Increasingly, specialist palliative care services offer telehealth consultations.

After-hours arrangements should be put in place as early as possible to reduce distress and uncertainty for patients and carers; the details should be clearly documented and easily accessible to the patient and their carers. Many after-hours issues involve carer anxiety about changes in symptoms or medication queries, and can be easily resolved over the phone. Difficulty accessing medical advice can be a reason for admission of a patient to hospital.

The GP is often the primary medical provider and coordinator of care for patients in the community. Quality general practice care provides access to home visits for regular patients both within and outside normal opening hours, and arrangements for after-hours care. For details, see the RACGP Standards for General Practices.

If the GP is unable to visit a patient with palliative care needs at home, they should let the patient know and help to organise alternative arrangements. If after-hours care is anticipated and will be provided by another healthcare professional, the GP should ensure there is appropriate written information at the patient’s home, including the patient’s medical history and an up-to-date medication list. Preferably, there should also be a letter to the ambulance service stating that the patient is receiving palliative care, and a copy of the patient’s advance care plan that includes instructions regarding resuscitation measures.

Considerations when providing after-hours palliative care to a new or unfamiliar patient include:

• Background information—Clarify the extent of disease, recent disease progression and the goals of care as much as possible. This information may be sought from the patient, a family member or carer, or the referral source.
• Expectations—Ask the patient and family or carers what they expect from the consultation, especially when seeing a patient for the first time.
• Advance care plan—Check the patient’s advance care plan, if available.
• Assessment of change in function—If the patient’s function has changed, consider whether it was an expected or unexpected deterioration and how rapidly the change occurred. A patient who was mobile yesterday and is now unexpectedly comatose is very different from a patient who has been bed-bound for several weeks and has gradually lost consciousness over a couple of days.
• Clinical decision-making and symptom management—Consider whether a deterioration could be reversible; however, active treatment is not beneficial in all situations (eg pneumonia in the last days of life). If an intervention (eg transfer to emergency department) is being considered, make a careful clinical assessment including whether an intervention fits with the patient’s goals and preferences.
• Care in the last hours of life—If the patient is comfortable, then no additional treatment needs to be provided. For advice on care in the last hours to days of life, see Care in the last days of life.
• Deceased patient—see After-death care.
• Follow-up—Ensure that the result of the visit is communicated to the patient’s regular healthcare professionals (eg GP, community nurse, specialist palliative care team) so that follow-up can occur.