Synopsis
Build a shared, operational community plan that anticipates deterioration, makes preferences and treatment ceilings visible, secures medicines, equipment and staffing and gives patients and carers a reliable response at night and weekends.
- Community palliative care works only when the plan can be found and acted on by general practice, district nursing, hospice, ambulance, pharmacy and out-of-hours teams.
- First-line planning identifies the person's goals, decision-making capacity, preferred contacts, likely crises, current treatment, care setting and what would make remaining at home unsafe.
- Record an advance statement, valid advance decision to refuse treatment and health-and-welfare attorney separately; they have different legal effects and jurisdictional rules.
- A DNACPR or ReSPECT recommendation addresses emergency treatment decisions but does not create a blanket instruction against admission, antibiotics, fluids or symptom relief.
- Send a concise electronic handover containing diagnosis, trajectory, baseline function, allergies, key medicines, treatment ceiling, preferred place, family capacity and named professional contacts.
- Anticipatory prescribing must be individual: medicine, concentration, dose, route, interval, indication and escalation need to match opioid exposure, organ function and likely symptoms.
- Verify that medicines are physically in the home, in date and accessible to an authorised administrator; an electronic prescription alone does not provide night-time relief.
- Arrange equipment and care before crisis, including pressure mattress, commode, continence supplies, syringe driver access, moving support and overnight contingency.
- Give carers one visible plan for whom to call, what changes are expected, which symptoms are emergencies and what to do if they can no longer provide care.
- Review after every admission, major deterioration, medicine change or caregiver change because a previously safe home plan can fail quickly.
Key red flags
A missing or contradictory emergency-care document creates immediate risk and needs same-day clinical reconciliation.
No accessible anticipatory medicine or authorised administrator over a weekend requires urgent service escalation before symptoms occur.
A carer saying they cannot continue tonight is a care emergency, not a request to defer until routine hours.
New severe breathlessness, stridor, haemorrhage, seizure or unresponsive collapse must follow the event-specific emergency plan.
A patient with capacity withdrawing consent for information sharing or home care requires immediate plan revision.
Safeguarding concerns, coercion or diversion of controlled drugs require confidential assessment and formal escalation.
An advance decision whose validity or applicability is uncertain should prompt urgent senior advice rather than unsupported treatment refusal.
Severe uncontrolled symptoms, major haemorrhage, prolonged seizure, stridor, sudden collapse or immediate caregiver loss requires the pre-agreed urgent or emergency route.
Investigation priorities
Clarify priorities, capacity, preferred place, acceptable treatments, household environment and the voluntary ability of carers to support care.
Management branches
Progressive illness makes deterioration or loss of decision-making capacity foreseeable.
- Explore goals, acceptable outcomes, preferred people and place and explain advance statements, refusal documents, attorney roles and emergency recommendations accurately.
- Record scenario-specific decisions about resuscitation, transfer and burdensome treatments using the lawful local forms and communication support required.
- Share the agreed summary with consent across all likely responders and give patient and carers an accessible version and review date.
Symptoms or function worsen outside routine service hours.
- Responder retrieves the shared summary, confirms current capacity and wishes and assesses the symptom and any reversible or emergency cause.
- Deliver authorised home treatment and non-drug care when safe, or arrange emergency transfer when severity, reversibility or support exceeds the home plan.
- Document treatment, response and any changed ceiling, reconcile supplies and notify the daytime responsible team for prompt review.