207-1216 / Rapid Discharge Planning Guidance for Patients Who Wish to Die at Home

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
HSE National Clinical Programme for Palliative Care, Clinical Strategy and Programmes Directorate.


Clinical guidelines or pathways
Handover situations / Transfer of patients
GOP Description
Implementation level
Clinical settings
The document has been formally launched and available to all acute settings in Ireland in 2014.
Guidance on the safe transfer for patients in acute settings who are nearing end of life and wish to die at home. The document outlines method and implementation process as well as the roles and responsibilities of team and supersedes the HSE Integrated Discharge Planning process.
First target population are patients and their family/carers to accommodate their wishes. Second are health and social care professionals in acute and community settings who have a role to play in discharge planning.
Methodology is outlines in a step-by-step basis in the document under the following headings:
• Medical discharge decision following expression of wish by patient to die at home and agreement to support by family
• Staff member nominated to take the lead in the discharge process
• Initial communication between hospital and primary care services: GP and PHN Nursing Service/ residential care service manager/ pharmacy/ ambulance service/ home care services etc.
• Preparing the rapid discharge plan and agree time and date
• Communicating with patient and family about the rapid discharge planImplementing the rapid discharge plan throughout the HSE acute services under the following headings:
• Equipment
• Services
• Discharge medication
• Carer education and support
• Transport
• Timing of discharge
• Handover communication
• Day of dischargeAddress issues that may arise during process:
• Concerns raised by GP or Public Health Nurse
• Concerns raised by families
• Guidance on issues/actions regarding organ donation, post mortem, certification of death, death during transport
Timeframe implementation
Once implementation is agreed within organisation key staff education on the process will take approx 2 hours.
Implementation tools available
Guidance document and support tools and templates to guide staff through the process including:
o Explanation of Rapid Discharge Planning process
o Rapid Discharge Action Plan and Checklist
o Sample Rapid Discharge Record
o Carer Education and Support Prompts
o Sample Letter for Ambulance Transfer
o List of Frequently Asked Questions
o PowerPoint presentation on the method and application of the Rapid Discharge Planning process
Implementation cost
Cost based on 2 hour key staff education on use of the process and new knowledge shared within team.
Method used to measure the results
Evaluation not undertaken by Clinical Programme team and will fall under standard organisation process evaluation
Analysis of the results
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
Expressed issues from sites include access to home care packages at short notice, suitable equipment for home use and time to implement process in the workplace.
Describe the strategies used to overcome the barriers (If needed)
Discussions with HSE Social Care on possibility of dedicated home care packages at short notice for patient cohort. Exploration of issues regarding availability of equipment required at short notice.
Other information
Other information about the GOP that you would like to add (Link or attached document)
The document and resources are available on the programme website: www.hse.ie/palliativecareprogramme
201511260139238527_760_GOP_Rapid discharge guidance document.OCT 2015.pdf