Overview - Transfers - Managing Risk


Some people may want or need to transfer between care settings during the palliative phase as their preferences and circumstances change. For example, they might transfer:

  • to a hospital (for emergency and acute care)
  • to a hospice or palliative care service (for specialist end of life care)
  • to a private residence (e.g. home of a family member)
  • back to a residential care facility from their family home, community or health service.

When transferring people between care settings in the palliative phase, the outcomes sought include:

  • involving the person and their family (if the person consents), or, where appropriate, the person’s substitute decision-maker in choices and decisions relating to transfer and treatment
  • maximising comfort and quality of life for the person including minimising ‘transfer related’ stress and anxiety for the person and others
  • ensuring clarity for those caring for the person, both within the transferring environment and the receiving environment
  • ensuring the person continues to receive safe and quality care that meets their needs and preferences
  • minimising unnecessary disruption to the person’s care, medications and treatments.

Managing transfers between care settings for people nearing the end of life can be challenging and involve many considerations. Effective risk identification and management underpins the delivery of safe, effective, and person-centred care.

This resource seeks to assist staff working in residential aged care to identify and address some of the key risks – be they legal, clinical, or communication risks - associated with transfers between care settings during the palliative phase.

It does not provide a comprehensive assessment of all risks, but rather prompts staff to apply risk-based thinking (noting that there will be different risks relevant to different people and aged care facilities).

This resource integrates principles and requirements of the Aged Care Quality Standards including person-centred and rights-based care, consumer dignity and choice, dignity of risk, quality of life, ongoing assessment and planning to reflect a person’s needs, goals and preferences, and continuous improvement. It also draws on the National Palliative Care Standards including comprehensive assessment of need, care planning and quality improvement.

The Aged Care Quality Standards are currently being revised and strengthened.

The existing Standards [Standard 3(3c)] require ‘the needs, goals and preferences of consumers nearing the end of life are recognised and addressed, their comfort maximised and dignity preserved.’

The Consultation Paper: Aged Care Quality Standards Review signals the intent for a more detailed focus on end of life care. A new dedicated Standard on Food & Nutrition, and more detailed requirements for Clinical Care (e.g., choking and swallowing and malnutrition and dehydration risks) are foreshadowed. The strengthened Quality Standards are due to come into effect in mid-2024.

Page updated 18 January 2024