Home Based Palliative Care: Supporting People to Stay at Home, with Dignity and Choice
When someone is diagnosed with a life-limiting illness, the focus often shifts from long-term planning to what matters most right now: comfort, dignity, and quality time with loved ones. For many people, this also means a strong wish to remain at home for as long as possible.
Our Palliative Care Program supports individuals with a life-limiting illness who wish to receive end-of-life care in their own home. The program provides practical, personalised, non-clinical support that helps clients manage daily needs, remain safe, and spend meaningful time with family and friends in familiar surroundings.
1. Service Snapshot
Our Home Based Palliative Care service exists to help individuals and families navigate the end-of-life stage with greater support and stability. The program focuses on enabling clients to live at home with dignity, by coordinating the right services at the right time.
While clinical care is delivered through health providers such as community nursing and palliative care teams, our Home Based Palliative Care team plays a vital role in ensuring that non-clinical support is in place to meet everyday needs.
The program operates through a brokerage model, meaning support workers are engaged through external agencies, with services delivered under the program’s direction and ongoing case management.
2. Who Home Based Palliative Care Supports
The program supports a wide range of clients requiring palliative care, including individuals with:
- terminal cancer
- neurodegenerative conditions
- rapidly progressing dementia
- chronic and debilitating illnesses that reduce independence
Clients may require minimal assistance initially, while others may have complex needs including being bedbound, requiring high levels of personal care, or needing multiple services and equipment arranged quickly.
Importantly, the program also supports carers and families, who are often overwhelmed, exhausted, or unsure what services exist. It is common for the first contact to come from a family member seeking guidance and reassurance.
3. How Clients Access the Service
Clients access the Palliative Care Program through a variety of pathways. Referrals commonly come from:
- hospitals and discharge planners
- hospice services
- community nursing teams
- palliative care services
- social workers
- family members or self-referrals
- community recommendations
Many referrals occur after a hospital admission or when symptoms worsen and care needs increase. The program responds by gathering information, assessing suitability, and helping clients connect with appropriate supports. If the service is not the right fit, staff aim to refer clients to other services that can assist.
4. What Support Looks Like in Practice
In palliative care, needs can change quickly. The program provides flexible and responsive support tailored to each client’s situation.
One of the most common requests is personal care. Many clients do not wish for intimate care tasks to be carried out by family members, and having a trained support worker can help preserve dignity while reducing stress for carers.
Support often begins with a home visit to assess safety, identify equipment needs, and understand the client’s daily routine and goals. Equipment may be accessed through hospital or hospice occupational therapists, or through equipment loan services.
Once needs are confirmed, the program brokers support workers through external agencies and provides ongoing monitoring, review, and adjustments over time.
Support may include:
- personal care and hygiene support
- household tasks and daily living assistance
- coordination of equipment and home modifications
- referrals to counselling and emotional support
- linking carers with respite services and Carers ACT
- connection to community-based programs and social supports
Even small amounts of support can make a major difference, particularly for carers who may only need short periods of relief to continue managing at home.
5. A Client Journey (Case Study Example)
One example involved a woman in her late 40s who had recently moved to Canberra with her husband for work opportunities. They were settling into a new home and preparing for their child to start high school when she received a diagnosis of metastatic ovarian cancer.
Treatment began, but unfortunately chemotherapy was not successful. As her condition declined, home-based nursing became involved to support medication and symptom management. The Palliative Care Program was introduced to provide additional support at home.
Initially, a support worker assisted with practical tasks such as bed making and household routines. Over time, a trusting relationship developed, and support expanded to include personal care. The support worker became a consistent presence in the home and built rapport not only with the client but also with her family.
During this period, the family experienced a second tragedy when one of the woman’s adult children was killed in an accident. In response, the program supported the family to access counselling services through the Cancer Council, and additional support was arranged for the younger child through hospice services.
Despite the immense grief and complexity, the program helped the family create meaningful moments together. Support was provided to help the woman celebrate her 50th birthday through a family picnic and an early Christmas gathering. She passed away shortly after, surrounded by family and in the place she wished to be.
6. Outcomes and Why This Service Matters
The Palliative Care Program supports clients to remain at home, with dignity, comfort, and control. It also provides vital guidance to families navigating an unfamiliar and emotional stage of life.
Outcomes include:
- improved quality of life and comfort at home
- reduced carer stress and burnout
- better coordination of supports and equipment
- increased confidence and empowerment for families
- improved connection to counselling, respite, and community services
Above all, the program helps ensure people can spend their final stage of life in their preferred environment, supported by family, friends, and a coordinated network of care.
