The AHP Team Lead’s task is to consider whether Esther could have gone home. Statistics on the number of people dying at home vary by medical condition and currently the majority of deaths from acute stroke occur in hospital. It is useful to check what happens in your own health board area.
The AHP Lead understands that many people will express a preference to die at home, however after an acute event such as a stroke when family are faced with the reality, many may change their minds and want more extensive support.
In Esther’s case, not achieving a discharge home should not be viewed as a team failure. Esther’s deterioration was unpredictable and therefore the opportunity to plan was limited. However stroke services should be aware of the agreed aim to increase the number of people who die in the location of their choice as specified in the national strategies, such as the 2008 report Living and Dying Well: Living and dying well (PDF, 489KB), and the 2015 Strategic Framework for Action, to improve palliative and end of life care. Liaison with primary care teams is essential to ensure the appropriate nursing and supportive care package is in place. Dying at home is considered an indicator of ‘quality of death’ by Healthcare Improvement Scotland.
Esther’s wishes for preferred place of death had been verbally expressed to her family but she did not have a formal anticipatory care plan. What is an anticipatory care plan?
Decide whether you could facilitate a discharge home, and consider whether they could have applied to Esther.
Advance care plan?
Esther was fit and well prior to her stroke and has not taken part in formal care planning. Admission details should include checking if an advance care plan is in place.
Prognosis agreed?
Prediction of care need is inherently difficult after stroke particularly when Esther has no history of other progressive deterioration and frailty. The team would need to have agreed that Esther was for supportive care only.
Family/carer commitment to discharge home?
A carer assessment would have been appropriate to ensure Esther’s family had all additional support needs addressed.
Specialist equipment available?
Local provision of equipment such as mattresses for pressure relief and continence aids can vary but should be checked to determine whether a fast track discharge can be achieved.
Fast track palliative discharge available?
Provision of a specialist fast track palliative care discharge service that can support same day discharge could be an appropriate service for Esther if locally available.
Provision of food and fluid?
The provision of oral fluid and nutrition is part of basic care. Due to Esther’s low conscious level a decision would have to be made on whether to continue subcutaneous fluids at home and who will manage this.
Administering medication?
Care may be provided by the primary care team with input from a specialist palliative care service. The provision of a “Just in Case” medication box may be appropriate (see Additional Information box for further information).
Suitable transport?
Consideration should be given on how appropriate it is to move Esther whilst severely unwell. The ambulance service and primary care team should be provided with appropriate documentation including DNACPR.
Page last reviewed: 08 Nov 2021
