Transferring critically ill patients home to die: developing a clinical guidance document

BACKGROUND: With preferred place of care at the time of death a key consideration in end of life care, it is important that transfer home be considered for critically ill patients who want this as part of their end of life care. However, there is limited guidance available to inform the transfer of critically ill patients home to die. AIMS AND OBJECTIVES: To develop clinical guidance on the practice of transferring patients home to die for doctors and nurses in critical care. DESIGN: Consensus methodology. METHODS: At a one-day national event, stakeholders from cross-community and hospital settings engaged in group work wherein 'virtual clinical teams' mapped out, and agreed on, the processes involved in transferring critically ill patients home to die. Using two clinical cases and nominal group technique, factors were identified that promoted and inhibited transfer home and areas in need of development. Findings from the day informed development of a clinical guidance document. RESULTS: Eighty-five stakeholders attended the event from across England. The majority of stakeholders strongly agreed that transfer of critically ill patients home to die was a good idea in principle. Stakeholders identified 'access to care in the community' (n?=?22, 31.4%) and 'unclear responsibility for care of patient' (n?=?17, 24.3%) as the most important barriers. Consensus was reached on the processes and decision-making required for transfer home and was used to inform content of a clinical practice guidance document. This underwent further refinement following review by 14 clinicians. A final document in the form of a flow chart was developed. CONCLUSIONS: Transferring critically ill patients home to die is a complex, multifactorial process involving health care agencies across the primary and secondary care interface. The guidance developed from this consensus event will enable staff to actively consider the practice of transferring home to die in appropriate patients.