Dying well at home: the case for integrated working

Coordinated care: health and social care and housing

Working together to support people dying at home

It’s much easier to look after somebody with dementia if you’ve known them for years and years ... you’ve seen them gradually decline and you sort of know yourself that they’re slowly dying.

GP [38]

You would like not to have to rush off; you would like to do the little things that just make that person’s life a little bit more variable ... and that’s heartbreaking when you’re having to drive away ...

Community nurse [39]


Professionals and providers should:

  • Ensure that networks and coordination arrangements are in place to enable health and social care professionals (including those responsible for arranging and delivering the care) to work together and share their knowledge.
  • Ensure that patients/service users and carers see the same familiar staff where possible, and have a single nominated person to contact for advice who has influence across health and social care.
  • Ensure that professionals are able to work flexibly and are responsive to the needs of patients/service users and carers.
  • Ensure that GPs identify people approaching the end of life, and discuss and record end of life issues with patients/service users and their families. Ensure that the new electronic primary care registers are used to coordinate care and take account of people’s wishes.
  • Recognise the vital contribution that district and community nurses make to end of life care. Invest in the recruitment, training and supervision of health and personal care assistants as well as domiciliary care staff.
  • Ensure that patients/service users and carers can access specialist advice and support ‘out of hours’, including essential medication and drugs for pain control.
  • Ensure that advance care planning documents are accessible to out-of-hours and ambulance staff.
  • Ensure that home care (or domiciliary) workers, healthcare assistants and extra care housing workers are trained and supported to work with people dying at home and their carers.
  • Consider the role that social workers can play in supporting people at the end of life.

Commissioners should:

  • Develop joint protocols between ambulance services, secondary care staff and primary care staff in relation to resuscitation – do not attempt cardiopulmonary resuscitation (DNACPR) – orders, and other relevant documents on patient choices for care.
  • Work to speed up hospital discharge so that people do not die in hospital while waiting for community nursing cover, equipment or transport.

Key points from research and policy

Specialist palliative care

The active, total care of patients with progressive advanced disease and their families. Care is provided by a multi-professional team who have undergone specialist palliative care training. The aim of the care is to provide physical, psychological, social and spiritual support.

Tebbit [40]

Generalist palliative care

Care providers working together

Practice examples

  • Practice example 2 describes a training initiative developed by local authorities in partnership with adult education services to equip domiciliary workers for end of life care.
  • Practice example 3 shows some of the outcomes for patients when primary care staff adopt the Gold Standards Framework for supporting people to die at home.
  • Practice example 5 describes a 24-hour support and coordination service – Partnership for Excellence in Palliative Support (PEPS) – which provides palliative care support, accessed through a single contact point.
  • Practice example 10 describes the Amber Care Bundle for specific use with people who have had a stroke.


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Available downloads:

  • Dying well at home: the case for integrated working
  • Dying well at home: research evidence