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Hospital transfer at the end of life

Residents & families GPs & clinicians Facility leadership 7 min read

By Dr Josh Hatch, FRACGP

For a resident with advanced illness, going to hospital can help, and it can also mean tests, procedures and a strange place the person would not have chosen. The aim is a decision made in advance with the person, not a reflex in the middle of the night. In the last days of life, the Quality Standards ask providers to minimise unnecessary transfer to hospital where this is in line with the person’s preferences 3.

Numbers in the text link to the 8 sources listed at the foot of this page.

What the data show

In Australia in 2021–22, 29% of residents appraised as needing palliative care needed hospital leave during their time in permanent residential care 2.

The largest study of transfers near the end of life comes from the United States. Among 474,829 nursing home residents with advanced cognitive and functional impairment who died between 2000 and 2007, 19% had at least one burdensome transition, such as a hospital transfer in the last three days of life or several hospital stays in the last 90 days. Residents in regions with the most burdensome transitions were more likely to have a feeding tube, time in intensive care in the last month and severe pressure injuries 14. This was observational data from another health system, so it shows association, not cause 14.

Weighing it up

Neither staying nor going is right for everyone. These are the questions that help.

  • Can hospital do something the facility cannot?. Surgery for a broken hip to relieve pain, a procedure, or a test that would change the plan.

  • Would the person want it?. Some people want every available treatment. Others have said they want to stay where they are. Their documents and their substitute decision-maker are the guide.

  • Can the symptom be managed where they are?. Pain, breathlessness, nausea and agitation can be treated in the facility when medicines and a plan are ready ahead of time.

  • What would the trip involve?. Ambulance transport, waiting in an emergency department, and care from people who do not know the resident.

Programs to reduce transfers: the evidence

Graded on randomised evidence for hospital transfer and related outcomes in nursing homes.

Specialist palliative care “Needs Rounds” in the facility

Promising, not yet proven

Outreach by specialist palliative care clinicians to the care home reduced hospital admissions and time in hospital in Australian care homes.

The evidence

In a stepped-wedge randomised trial of 1,700 residents in 12 Australian care homes, hospitalisations fell by 23%, from 5.6 to 4.3 per facility-month, and adjusted length of stay was 0.22 days shorter 16.

In practice

One trial, in one region, and masking was not possible 16.

A structured advance directive program

Promising, not yet proven

Fewer hospital admissions per resident in one small trial.

The evidence

Intervention homes had 0.27 admissions per resident against 0.48 in control homes over 18 months 6.

In practice

Six homes in Ontario in the 1990s 6.

Advance care planning videos

Not supported

No significant reduction in hospital transfers in 360 nursing homes.

The evidence

Transfer rates were 3.7 against 3.9 per 1,000 days, a difference that was not significant 7.

In practice

Low uptake. A post hoc analysis of residents who died found a small reduction in the last 90 days of life 17.

Staff training in an acute-change and transfer-avoidance toolkit (INTERACT)

Not supported

Training and implementation support alone did not change hospital admission or emergency department visit rates.

The evidence

In 85 US nursing homes with 36,717 residents, there was no significant change in all-cause admissions, readmissions or emergency visits. A reduction in potentially avoidable admissions did not survive correction for multiple comparisons 15.

Deciding in advance

The time to decide about hospital is before the crisis, with the resident if they can take part, and with the substitute decision-maker. A useful plan says, for the common events, whether the person would want to go to hospital, what treatment they would accept in the facility, and who should be called.

A plan that says “no hospital transfer” is not a plan to withhold care. It needs to be paired with what will be done instead: medicines ready in the facility, a nurse who can give them, and a doctor who can be reached. Where the person wants to stay, the facility needs to be able to keep them comfortable there 3.

Related pages on this site

Sources cited on this page

  1. 2 Australian Institute of Health and Welfare. Palliative care services in Australia: palliative care for people living in residential aged care. (2021–22 data, appraisal under the Aged Care Funding Instrument; section last updated May 2023.) View source
  2. 3 Australian Government Department of Health, Disability and Ageing. Strengthened Aged Care Quality Standards (November 2025; implemented 1 November 2025). Outcome 5.7 Palliative care and end-of-life care, Actions 5.7.1 to 5.7.4. View source
  3. 6 Molloy DW, Guyatt GH, Russo R, et al. Systematic implementation of an advance directive program in nursing homes: a randomized controlled trial. JAMA. 2000;283:1437–44. (Six Ontario nursing homes, pair-matched, one home per pair randomised.) View source
  4. 7 Mitchell SL, Volandes AE, Gutman R, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial (PROVEN). JAMA Intern Med. 2020;180:1070–8. (360 US nursing homes.) View source
  5. 14 Gozalo P, Teno JM, Mitchell SL, et al. End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med. 2011;365:1212–21. (Observational; US Medicare data, 474,829 decedents, 2000–2007.) View source
  6. 15 Kane RL, Huckfeldt P, Tappen R, et al. Effects of an intervention to reduce hospitalizations from nursing homes: a randomized implementation trial of the INTERACT program. JAMA Intern Med. 2017;177:1257–64. (85 US nursing homes.) View source
  7. 16 Forbat L, Liu WM, Koerner J, et al. Reducing time in acute hospitals: a stepped-wedge randomised control trial of a specialist palliative care intervention in residential care homes. Palliat Med. 2020;34:571–9. (1,700 residents in 12 Australian care homes.) View source
  8. 17 Moyo P, Loomer L, Teno JM, et al. Effect of a video-assisted advance care planning intervention on end-of-life health care transitions among long-stay nursing home residents. J Am Med Dir Assoc. 2022;23:394–8. (Post hoc analysis of the PROVEN trial.) View source

See every source cited across the palliative and end-of-life care section →

Written by Dr Josh Hatch, FRACGP. General information only, reflecting his reading of the published evidence as at October 2026. It is not individual medical advice, does not create a doctor–patient relationship, and must not be used to start, stop or change any treatment. It is not legal advice. Evidence, Australian regulatory requirements and state laws on advance care planning, substitute decision-making and voluntary assisted dying change — always confirm current advice with the treating GP, the state health department or a lawyer.

This is general education, not a clinical protocol. The doctors who practise with Umbrella Aged Care are independent general practitioners, and each makes their own clinical decisions with the resident and family. Your GP’s advice for an individual may differ from what is written here. If it does, please ask them to talk it through with you.

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