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Elderly and palliative care at home: plan around the person
Home support for older adults or people with serious illness should be built around the person's goals, comfort, function, dignity and family context. It needs a named care plan, responsible clinicians, medication reconciliation, communication, review and a clear escalation pathway.

What should a person-centred plan include?
The plan should record the person's priorities, diagnoses, medicines, allergies, communication and mobility needs, daily support, symptom goals, responsible professionals, family roles and what to do if needs change.
- ✓What matters to the person
- ✓Current health problems and medicines
- ✓Mobility, nutrition, skin and continence needs
- ✓Comfort and symptom priorities
- ✓Family and caregiver roles
- ✓Review, urgent contact and escalation plan
How should the care team work together?
Doctor, nurse, therapist, pharmacy, usual specialist and family should share an agreed plan with consent. Repeated handovers without one current record create avoidable gaps.
One current plan
Medicines, goals, responsibilities and recent changes in one place.
Named contacts
Know who manages routine questions, symptoms and urgent changes.
Regular review
Adjust support when function, symptoms or family capacity changes.
Respect
Include the person's preferences and consent in every decision.
What changes need prompt review?
New confusion, falls, reduced intake, uncontrolled pain, breathing change, fever, medication problems, skin breakdown or a sudden decline deserve prompt clinical review. Life-threatening symptoms require 998.
FAQ
Is palliative care only for the final days?+
No. Palliative care can support symptoms, communication and quality of life alongside other treatment, depending on the person's needs and clinical plan.
Can the family change medicines?+
Medication changes should be agreed with the responsible prescribing clinician.
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Home support for older adults or people with serious illness should be built around the person's goals, comfort, function, dignity and family context. It needs a named care plan, responsible clinicians, medication reconciliation, communication, review and a clear escalation pathway.