What happens when a person with dementia is discharged from hospital?

What is hospital discharge?

‘Discharge’ is the term used when a person leaves hospital. This should only happen once a doctor at the hospital decides that the person is ‘medically fit’. This means that the person no longer needs the same level of medical attention that they’ve been receiving in hospital.

The discharge process has changed significantly since the coronavirus pandemic began in 2020. It is likely to change even more with time. The discharge process may also be different depending on where people live. 

Assessment for hospital discharge

When does the hospital discharge assessment happen?

Currently, hospitals in England and Wales use a ‘discharge to assess’ model. This means that only a short assessment will be completed in hospital.

This is because the requirements for people staying in hospital are now stricter. This means that discharge can happen very quickly. People who need support after leaving hospital will be given a longer assessment.

Who does the hospital discharge assessment?

The professionals involved in an assessment (both before and after leaving hospital) could include:

• doctors, such as consultants
• nursing and ward staff
• physiotherapists
• occupational therapists
• social workers
• psychiatrists
• registered mental health nurses.

If a lot of people are involved in the assessment, it may help to make a list of the names of people you have spoken to and their contact details.

What does the hospital discharge assessment involve?

The assessment for hospital discharge should involve:

• considering the person’s needs, including: 
  • where they are currently living
  • their ‘support network’ (people involved in supporting them)
• writing out a care plan recording these needs
• setting up a system to: 
  • check that the care plan continues to meet the person’s needs over time
  • adjust the plan if those needs change
• looking into the person’s finances and checking their eligibility for different types of funding
• arranging any equipment and adaptations to help the person live safely at home – for example, grab rails, toilet frames or hoists. 

Once it has been decided that a person should be discharged from hospital, the person and their family or carer should be informed.

Hospital discharge process

If no extra support is needed after leaving hospital

For people who are well enough to return to their home setting with no extra support, the ward staff should arrange the discharge. The person should be transferred from their ward to a discharge area as soon as possible. They should be able to leave hospital the same day.

If some continued support is needed after leaving hospital

If the person will need continued support or care after leaving the hospital, they should be assigned a case manager. The case manager will work with ward staff to make sure that the person and their family are fully informed of the next steps. 

The case manager will:

• set out the person's discharge and follow-up care
• arrange transport and ‘settle in’ support, which could include services like help with shopping
• work with other teams of professionals, such as local ‘single point of access’ schemes, to set up an assessment of the person’s longer term needs once they have left the hospital.

If a high level of support is needed after leaving hospital

After a stay in hospital, some people will need a very high level of care. In this situation, the person may be kept in hospital. If the person cannot stay in hospital, they may be discharged to a care home or to a rehabilitation bed.

Will a person with dementia be discharged if they are nearing the end of their life?

If someone with dementia is nearing the end of their life, they will not usually be kept in hospital. Instead, the community palliative care team will organise for them to be discharged to a home or hospice. This is a new policy that was brought in because of the coronavirus pandemic.

Even after discharge from hospital, end of life care plans should still focus on supporting the person’s physical and spiritual needs. These plans should always involve the person and their family, as well as a number of different professionals.

If the person is in the last few hours of life

The discharge policy does not apply to people who are in their last few hours of life. If this is the case, the person will be kept in hospital.

Most hospitals have specific guidelines for care at the end of life. These ensure that:

• staff check in with the person and their relatives frequently and in a sensitive manner
• the person at the end of life and their family are involved in treatment and care decisions
• decisions about care are made according to the person’s needs and wishes
• care will focus on prioritising the person’s comfort and quality of life.

What support can the hospital offer if a person with dementia is in the last few hours of life?

This can be a very difficult time for everyone involved. Hospitals can provide help and support to make things as comfortable as possible for the person with dementia and their family, friends and carers. This can include:

• letting loved ones stay beyond visiting hours, or overnight
• if a room is available, moving the person with dementia from a main ward to a quiet side room.

You might also want to speak to a member of the palliative care team. They specialise in providing comfort and pain relief at the end of someone’s life.

If the person has any spiritual and cultural needs, such as the involvement of a faith leader, it is a good idea to make staff aware of these. 

Making decisions about end of life care

Depending on the nature of the person’s illness – for example, if the doctor feels the person is likely to have a heart attack – you may need to think about your and the person’s views on resuscitation. This is a medical process that can be attempted when a person’s heart stops beating. The medical team should always discuss this with the main carer or family members. If anything is unclear, ask them to explain it to you in a different way. It may help to talk it through with family or friends.

The person may have set out their own wishes about their care at the end of life, including resuscitation, in an advance decision. These must be followed.