End-of-Life Pathway and Palliative Nursing Services

Support at Home End-of-Life Pathway

The End-of-Life Pathway is a new short-term, high-priority care option under the Support at Home program that commenced on the 1 November 2025 to help older people in their final months of life remain at home with dignity. Eligible individuals (generally age 65+ with a terminal prognosis of ≤3 months) can receive an additional one-off funding allocation of $25,000 for home care services over a 12-week period.

This funding is intended to urgently meet care needs – including nursing, personal care, respite, and equipment – during the last stages of life. Importantly, clinical support services such as nursing are fully funded by the government with no client co-contribution required.

Funding for the End-of-Life Pathway is discrete from other Support at Home classifications. If an existing Support at Home participant moves to the End-of-Life Pathway, this will replace their ongoing classification. Please contact ECH on 1300275324 if you have questions on these classifications.

The End-of-Life Pathway Form

An End-of-Life Pathway Form is required to be completed and submitted before a participant can be assessed as eligible for the End-of-Life Pathway. The form captures specific medical information related to the participant’s medical condition and evidence of end-of-life. The participant, their registered supporter or active, appointed decision-maker, or the provider must download the form and provide this to the appropriate medical practitioner (their GP, non-GP specialist or nurse practitioner) for completion. Upon completion, the form will need to be submitted for consideration by an aged care assessor.

The End-of-Life Pathway Form can be downloaded from the department’s website.

An End-of-Life Pathway fact sheet is available to assist medical practitioners to understand the program requirements and how to complete the End-of-Life Pathway Form.

Palliative Nursing Services

Enrolled Nurses (ENs), Registered Nurses (RNs), and Clinical Nurses (CNs) deliver specialised in-home palliative care services for clients on the End-of-Life Pathway. All care is person-centred and tailored to each client’s needs and wishes, in collaboration with the client’s family and existing care team. Service to be provided:

• Initial Nursing Assessments & Care Planning: Conduct thorough in-home assessments of the client’s condition, care needs, and environment. Develop individualised care plans and written task instructions for other carers to follow, ensuring clarity in daily care routines.
• Symptom Management: Ongoing monitoring and management of distressing symptoms – e.g. effective pain control, relief of nausea/vomiting, management of dyspnea (breathlessness), anxiety or delirium – using both pharmacological and non pharmacological interventions. Nurses will regularly assess symptom severity and adjust strategies in consultation with the client’s GP or specialist as needed.
• Medication Management: Safe administration of medications (including injectables, infusions, and breakthrough analgesia) and oversight of medication schedules. This includes setting up medication charts, supervising doses for symptom relief, and ensuring prompt access to prescribed end-of-life medications.
  Wound Care: Provision of wound management for any pressure injuries, surgical wounds, or skin breakdown issues common in palliative patients. This includes regular wound assessments, dressing changes, and strategies to promote comfort and healing.
• Incontinence & Skin Care: Support with continence care (catheter care, continence product management) and maintaining skin integrity. This involves preventive skincare, pressure area care, and hygiene to keep the client comfortable and reduce risk of pressure sores. Emotional Support & Family Education: Provide emotional support to clients coping with terminal illness, and guidance to family members. Nurses offer empathetic listening, basic counselling, and educate family/carers on what to expect as the illness progresses. We ensure families are involved in care decisions and feel supported throughout the process.
• End-of-Life Planning & Comfort Care: Assist with advance care planning discussions and implement comfort care measures as the client’s condition evolves. This includes implementing end-of-life care plans that respect the client’s preferences (e.g. preferred place of death, cultural/spiritual wishes) and prioritising comfort (such as positioning for ease of breathing, mouth care, pressure relief, etc.).
• Liaison with External Palliative Services: Liase with GPs, specialist state-funded palliative care teams, and hospice services to coordinate care. This collaboration ensures clients have access to specialist resources (e.g. palliative care consultants, after hours advice lines) and that care is well-integrated.
• Bereavement Support Guidance: Although our direct care concludes when the client passes away, we will provide family members with guidance on bereavement support. This may include information on grief counselling services, support groups, and follow-up phone calls to check on family well-being after the loss.

Hours of service

Our palliative nursing team is available 7 days a week, 24 hours/day including Over Night Respite. We can also arrange on-call phone support for urgent after-hours palliative issues as required.

Service Timing

We understand the urgency of end-of-life referrals.

Following receipt of a referral, an initial nursing assessment/home visit will occur within 24 hours (often same-day or next-day). This rapid response ensures that urgent needs are addressed promptly. For any non-urgent inquiries or pre-Pathway consultations, we will schedule an assessment within 3 days at most. Once the care plan is in place, our nurses will provide ongoing visits as agreed (e.g. daily, several times per week, or as needed). We remain flexible to increase frequency if the client’s condition deteriorates or to decrease if appropriate. Our goal is to be responsive and adjust the service intensity to best support the client’s comfort and family’s needs.

Service Coverage Area

We offer in-home nursing throughout the Adelaide metropolitan region and surrounding areas up to 50 km beyond the metro boundary. This includes the Adelaide CBD, suburban areas, and towns within roughly a 50 km radius of metro Adelaide. If a client resides just outside this range, we are happy to discuss options – our priority is ensuring access to care. Nurses will be dispatched from the nearest available location to minimise delays. All efforts are made to promptly cover referrals across this service area, while keeping travel time reasonable.

Referral and Service Initiation How to Refer for Service

• Referral Submission: Please complete the Referral and Intake Request Form for palliative care and send it via email to [email protected]. or submit a referral through our website’s referral portal.
• Confirmation: Once we receive the referral, our intake nurse will review the details immediately. This service request will be considered and responded to as soon as possible with confirmation of acceptance. Given the urgency of end-of-life care, we aim to confirm and commence services within 24 hours. We will reach out to the referrer (and client/family if appropriate) promptly to discuss the next steps and arrange the initial visit.
• Urgent Referrals: For any same-day urgent referrals or queries, you can also call us directly at 1300 450 190. We have a Clinical Nurse Consultant on call who can facilitate rapid deployment of a nurse when required.