Terminal discharge of the imminently dying from hospital to home: A realist evaluation.

Abstract

Rapid terminal discharge home is increasingly prevalent, yet processes remain inconsistent and stressful for both clinicians and families. A harmonised 'compassionate discharge' protocol was collaboratively developed by providers across settings to improve overall experience. How, for whom, and in what circumstances does the new pathway foster a positively experienced live terminal discharge? A mixed-methods realist evaluation was adopted to study the novel Compassionate Discharge intervention that embedded eligibility checks, customised resources and standardised workflows. Data collected from caregivers, hospital and hospice providers through surveys, diaries and interviews were analysed using abductive and retroductive reasoning to refine early Context-Mechanism-Outcome configurations and iterate an Initial Programme Theory. The multi-centre study involved referring hospital staff (<i>n</i> = 66), home hospice providers (<i>n</i> = 48), and family caregivers (<i>n</i> = 51) linked to specific patients who were compassionately discharged home alive as cases. Caregiver preparedness was associated with adequate information from hospital and caregiver training, while discharge experience was associated with perceived benefits from caregiver training and hospice end-of-life support. Six contextual conditions and nine mechanisms influenced three outcomes. Key mechanisms included timely recognition of dying, aligned family decision-making, structured handovers, hospital palliative team support, and targeted instrumental and psycho-emotional support for caregivers. Ultimately, successful terminal discharges depended less on information and skills transfer than on managing uncertainty and expectations across patients, caregivers and providers. A protocolised pathway that spans hospital and hospice can better prepare families to support good deaths at home while improving provider experience.