Home Discharge of Palliative Patients in Shock – Evidence‑Based Recommendations

1. Decision Framework

• Confirm that the patient (if capable) and family understand that shock represents the dying phase and that discharge home prioritizes comfort over survival. – American Heart Association (based on Cardiovascular Research 2020 and European Journal of Heart Failure 2020) [1][2]
• Explain that death may occur rapidly after withdrawal of life‑prolonging treatments, potentially during transport or within hours‑to‑days after arrival home. – British Journal of Anaesthesia 2005 [3][4]

2. Medication Management

• Immediately discontinue all non‑comfort cardiovascular drugs (vasopressors, inotropes, diuretics, ACE‑inhibitors, beta‑blockers) unless they provide direct symptom relief. – Cardiovascular Research 2020 1
• Prescribe opioids (e.g., morphine or fentanyl) as first‑line agents for dyspnea and pain in the dying phase. – Annals of Oncology 2014 5
• Add benzodiazepines (midazolam or lorazepam) for anxiety, agitation, or respiratory distress. – Annals of Oncology 2014 5
• Use anticholinergics (glycopyrrolate or scopolamine) to control excessive respiratory secretions (“death rattle”). – Cardiovascular Research 2020 1
• Provide anticipatory prescriptions with clear, written instructions for emergency sublingual, buccal, or subcutaneous administration by family caregivers. – Annals of Oncology 2014 5

3. Device Management

• Deactivate any implantable cardioverter‑defibrillator (ICD) before discharge to prevent painful shocks during the dying process. – Cardiovascular Research 2020 and European Journal of Heart Failure 2020 [1][2]
• If formal deactivation cannot be completed, ensure a magnet is available at home for emergency ICD suspension. – Cardiovascular Research 2020 and European Journal of Heart Failure 2020 [1][2]
• Continue cardiac resynchronization therapy (CRT) pacing when it may reduce symptom burden. – European Journal of Heart Failure 2020 2

4. Family Preparation & Education

• Educate families about typical dying‑phase signs: progressive weakness, decreased responsiveness, irregular breathing (including apnea periods), mottled skin, and reduced urine output. – Cardiovascular Research 2020 1
• Instruct families on when to administer PRN comfort medications (e.g., give morphine for labored breathing or moaning). – Annals of Oncology 2014 5
• Confirm that families feel competent to give emergency medications; if not, reconsider home discharge. – Annals of Oncology 2014 5

5. Transport Considerations

• Arrange non‑emergency medical transport rather than an ambulance to avoid automatic resuscitation protocols. – (derived from evidence on avoiding life‑prolonging interventions)
• Administer prescribed comfort medications before departure and have additional doses available during transport. – Annals of Oncology 2014 5
• Assess patient stability: if death is expected within minutes‑to‑hours, it may be more compassionate to allow death in the hospital with family present. – Cardiovascular Research 2020 and British Journal of Anaesthesia 2005 [1][3]

6. Documentation Requirements

• Record a multidisciplinary discussion confirming the patient is in the dying phase and that goals of care are comfort‑focused. – Cardiovascular Research 2020 1
• Document patient/family understanding that discharge prioritizes comfort and that death may be imminent. – European Journal of Heart Failure 2020 2
• List all discontinued life‑prolonging medications with rationale. – Cardiovascular Research 2020 1
• Note hospice enrollment and confirmation of immediate home services. – (supported by the overall care pathway)

7. Criteria When Home Discharge Is Not Appropriate

• Family members are unwilling or unable to provide basic care or administer emergency medications. – Annals of Oncology 2014 5
• Hospice services cannot be arranged for the same day of discharge. – (implicit from the need for immediate support)
• Patient instability makes death during transport highly likely. – Cardiovascular Research 2020 and British Journal of Anaesthesia 2005 [1][3]
• Family holds unrealistic expectations about prognosis or believes the patient will improve at home. – European Journal of Heart Failure 2020 and Annals of Oncology 2014 [2][5]

8. In‑Hospital End‑of‑Life Care When Discharge Is Contraindicated

• Provide maximal family presence in a private room and continue the same comfort‑focused medication regimen used for home discharge. – Cardiovascular Research 2020 and Annals of Oncology 2014 [1][5]

Hospice Care Arrangements

Introduction to Hospice Care

• The American Thoracic Society confirms that hospice eligibility requires certification by a treating physician and hospice medical director that the patient's prognosis is terminal (more likely than not having less than 6 months of life) 6, 7
• Importantly, if a patient survives beyond 6 months in hospice, Medicare and other reimbursement organizations will continue coverage if patients still meet enrollment criteria 6, 7
• Patients do not need a "do not attempt resuscitation" order to enroll in hospice programs 7

Oral Feeding Concerns in Hospice Care

• In end-of-life situations, older persons with low nutritional intake in the terminal phase should be offered comfort feeding instead of enteral nutrition 8
• Enteral nutrition (tube feeding) is fundamentally a life-prolonging procedure 8
• Comfort feeding means offering whatever the patient likes to eat and drink orally, in whatever amount they desire, with covering nutritional requirements being entirely irrelevant 8
• The ESPEN guidelines explicitly state that voluntary cessation of nutrition and hydration is a legally and medically acceptable decision of a competent patient when chosen in disease conditions with frustrating prognosis and at the end of life 9
• There is no compelling evidence that dehydration or forgoing nutrition in the dying patient leads to significant suffering 10

Practical Steps for Discharge Planning

• Hospice care can be provided in multiple settings dependent on the patient's and family's needs and preferences 6, 7
• Most patients prefer to die at home, though this may not always be possible 6, 7
• Achievement of the preferred place of death is accepted as a quality indicator of good end-of-life care 11
• Home hospice requires adaptations to facilitate a "hospital at home" arrangement with increased reliance on primary care physicians and community-based nurses 11
• If discharging home with hospice, anticipatory prescribing should be implemented immediately 11
• Medications that might be needed urgently, including opioids, antiemetics, diuretics, benzodiazepines, and midazolam, should be prescribed 11

Medication Management in Hospice Care

• Medication deprescribing should be undertaken as a proactive, patient-centered approach 11
• Medications inconsistent with or irrelevant to the goal of patient comfort can be discontinued 12
• Medications for symptom palliation should be continued unless ineffective or causing distressing side-effects 12

Common Pitfalls to Avoid in Hospice Care

• Physicians may be reluctant to discuss hospice due to lack of skill in acknowledging or communicating that death is near 6, 7
• The prognosis of non-cancer patients may be more difficult to determine, but this should not prevent hospice referral when appropriate 6, 7
• Family members and loved ones should be invited and supported to visit the dying patient, with bereavement support offered after death 13
• Medicare requires patients to agree in writing that only hospice care (not curative care) can be used to treat their terminal illness 6, 7
• Withholding or withdrawing nutrition is ethically permissible and may improve some symptoms in the dying patient 14

Family Communication Strategy in Hospice Care

• Advance care planning should be routinely conducted or reviewed by clinicians with patients and their loved ones 13
• Family members often need repeated reassurance that other methods have been tried and that hospice is unlikely to shorten the patient's life 12
• They should be kept informed about the patient's well-being and what to expect 12
• After discharge, the family should be offered bereavement support and resources 13, 15
• The care team must provide supportive care to family members, including listening to their concerns, attention to grief and physical/psychological burdens, and awareness of any perceived feelings of guilt 12