Transfers

Key messages

• People living in residential aged care facilities and home care sometimes want or need to transfer between care settings during the palliative phase.
• Consent to transfer should be given by the person, or, if the person does not have capacity, their substitute decision-maker. When transfer is being considered:
  • health professionals and care staff should offer the person relevant information to help inform their decision-making about the transfer
  • the person’s preferences about transfer and treatment, including those expressed in an Advance Care Directive or other advance care planning documents, should be respected
  • the person has the right to refuse transfer and treatment, even if needed to keep them alive.
• Unintended and unnecessary transfers should be minimised for people in the palliative phase.
• Transfers have better outcomes if they are underpinned by effective planning, risk assessment, coordination, and communication with the person, their family (if the person consents), the person’s substitute decision-maker (if the person does not have capacity), and between care settings.
• Continuity of care between care settings is a priority. This requires current and comprehensive information about the person’s preferences and needs to be shared with those involved in the person’s transfer and subsequent care.