How should I manage and arrange discharge for a palliative patient in acute circulatory failure (shock) who wants to spend his remaining days at home with a relative?

Managing Discharge Home for a Palliative Patient in Shock

A palliative patient in shock who wishes to die at home can be discharged with appropriate hospice support, focusing on comfort measures rather than hemodynamic stabilization, but this requires immediate transition to comfort-focused medications, discontinuation of life-prolonging interventions, and robust family counseling about the dying process. 1, 2

Immediate Decision Framework

Confirm Goals of Care Alignment

• Verify that the patient (if capable) and family understand that shock represents the dying phase and that home discharge prioritizes comfort over survival. 1
• Document that curative or life-prolonging treatments (including vasopressors, inotropes, aggressive fluid resuscitation) will be discontinued in favor of symptom management. 1, 3
• Ensure the family understands death may occur rapidly after treatment withdrawal, potentially during transport or shortly after arriving home. 1

Medication Management for Discharge

Discontinue all non-comfort medications immediately:

• Stop vasopressors, inotropes, and diuretics as these are life-prolonging rather than comfort-focused interventions. 1, 3
• Discontinue disease-modifying cardiac medications (ACE inhibitors, beta-blockers) unless they provide direct symptom relief. 1, 3

Initiate and prescribe comfort medications:

• Opioids (morphine or fentanyl) are first-line for dyspnea and pain management in the dying phase. 1, 2, 3
• Benzodiazepines (midazolam or lorazepam) for anxiety, agitation, or respiratory distress. 1, 2
• Antiemetics (haloperidol, metoclopramide) for nausea. 2
• Anticholinergics (glycopyrrolate or scopolamine) for excessive respiratory secretions ("death rattle"). 1
• All medications should be prescribed in anticipatory fashion with clear instructions for emergency administration at home. 2

Device Management

• If the patient has an implantable cardioverter-defibrillator (ICD), it must be deactivated before discharge to prevent painful shocks during the dying process. 1
• Ensure a magnet is available at home for emergency ICD suspension if formal deactivation cannot be completed before discharge. 1
• Cardiac resynchronization therapy (CRT) pacing function can continue as it may reduce symptom burden. 1

Practical Discharge Arrangements

Hospice Coordination

• Enroll in home hospice immediately—this does not require a "do not resuscitate" order and can continue beyond 6 months if the patient survives. 2
• Arrange for hospice nurse availability within hours of discharge, ideally with a nurse present at home upon arrival. 2
• Ensure 24/7 hospice on-call support is established before the patient leaves the hospital. 2

Family Preparation and Education

The family must understand the realistic timeline and process:

• Death may occur during transport home or within hours to days of arrival. 1
• Common dying phase symptoms include progressive weakness, decreased responsiveness, changes in breathing pattern (including periods of apnea), mottled skin, and decreased urine output. 1
• Reassure family that withholding IV fluids and nutrition does not cause suffering in the dying phase and may actually improve comfort. 2

Provide specific instructions for medication administration:

• Demonstrate how to administer sublingual, buccal, or subcutaneous medications if the patient cannot swallow. 1, 2
• Give clear parameters for when to administer PRN comfort medications (e.g., "give morphine for labored breathing or moaning"). 1, 2
• If family members feel unable to administer emergency medications, reconsider whether home discharge is feasible. 1

Transport Considerations

• Arrange non-emergency medical transport rather than ambulance to avoid triggering automatic resuscitation protocols. 2
• Ensure comfort medications are administered before and available during transport. 1
• Consider whether the patient is stable enough for transport—if death is imminent (within minutes to hours), it may be more compassionate to allow death in the hospital with family present. 1

Critical Pitfalls to Avoid

• Do not continue vasopressors or inotropes "to get the patient home"—this contradicts comfort care principles and may prolong suffering. 1, 3
• Do not discharge without ensuring hospice services are immediately available at home—gaps in care during the dying phase are unacceptable. 2
• Do not assume family understanding—explicitly discuss that the patient is dying and may not survive the journey home. 1
• Avoid delaying ICD deactivation—shocks during the dying process cause severe distress to both patient and family. 1
• Do not prescribe inadequate quantities of comfort medications—ensure sufficient supply for at least 72 hours before hospice can deliver additional medications. 2

Documentation Requirements

• Document the multidisciplinary discussion confirming the patient is in the dying phase. 1
• Record patient/family understanding that home discharge prioritizes comfort over survival and that death may occur imminently. 1, 2
• Note all medications discontinued and the rationale (no longer consistent with comfort-focused goals). 1, 3
• Document hospice enrollment and confirmation of immediate home services. 2

When Home Discharge Is Not Appropriate

Reconsider home discharge if:

• Family members are unwilling or unable to provide basic care and medication administration. 1, 2
• Hospice services cannot be arranged immediately (same day). 2
• The patient is so unstable that death will likely occur during transport. 1
• Family has unrealistic expectations about prognosis or believes the patient will improve at home. 1

In these situations, facilitate death in the hospital with maximal family presence, private room if possible, and the same comfort-focused medication approach. 1