The phone rings at two in the morning. "Your mum's running a temperature and she's confused. Do you want us to call an ambulance?"
You have eight seconds, almost no information, and the certainty that whatever you say will be wrong. Say yes and it goes badly, and you sent her to a corridor. Say no and it goes badly, and you denied her treatment.
This page has one purpose: to make sure that call does not find you unprepared. The right decision is not made at 2 a.m. It is prepared beforehand.
1. What a transfer actually does to a very old person
Hospitals save lives, and for some things there is no alternative. But the costs deserve saying out loud:
- Delirium. An older person with dementia taken to ED at night — lights, noise, strangers, nil by mouth, none of her landmarks — very often becomes acutely confused. Delirium worsens outcomes and does not always fully resolve.
- Deconditioning. A few days in a hospital bed can undo walking that took a year to maintain.
- The ambulance ramping and the ED wait, which nobody factors in.
- Hospital-acquired infection and procedure-related risk.
None of that argues against transfer when transfer is needed. It argues for deciding deliberately rather than reflexively.
2. When hospital is the answer, no argument
- suspected fracture, especially a hip: it needs fixing, even at a great age;
- stroke signs — face droop, arm weakness, slurred speech: there is a treatment window and minutes matter;
- significant breathlessness, chest pain;
- acute abdomen, persistent vomiting;
- head injury, especially on a blood thinner;
- bleeding that will not stop;
- anything the home is not equipped to treat.
3. The Australian option most families do not know exists
Before the ambulance, there is usually a middle step — and it is the reason this article matters here more than in most countries.
Most states run a residential in-reach or Hospital in the Home service for aged care: a hospital-based team that comes to the facility to assess and treat residents on site, with IV antibiotics, fluids, bloods and imaging, precisely so that a resident does not have to be moved. Many regions also have after-hours locum GP services that visit aged care homes.
Two questions worth asking before any of this happens:
> "Does this home use a residential in-reach or Hospital in the Home service, and who do you call after hours?"
And on the night itself: "Can in-reach see her instead of the ambulance?"
Add to that the requirement for a registered nurse on site 24/7 in residential aged care, and a well-run home should be able to manage a great deal without moving anybody.
4. When it can often be avoided
- urinary or chest infection responding to treatment;
- dehydration, including subcutaneous fluids;
- fever in someone in the advanced stage of an illness, where transfer changes the outcome very little and the last weeks a great deal;
- a fall with no sign of fracture, with observation in place;
- a mild flare of something already known and managed.
5. Three questions to ask on the phone
- "What have you done already, and what can you do there tonight?"
- "What would hospital change, compared with what you can do?" The decisive question. If the answer is "they'd run the same tests", the answer is usually no.
- "Has the RN assessed her, and has a doctor been contacted?"
And a fourth: "Call me back in an hour." A great many situations resolve within the hour.
6. The document that prevents all of this
An Advance Care Directive — the name and the form vary by state and territory — lets a person with capacity record what treatment she would want and refuse, and name the person who speaks for her. A valid refusal of treatment is legally binding; the naming of a substitute decision-maker, enduring guardian or medical treatment decision maker determines who is asked when she cannot answer.
What matters practically
- It has to be findable. A directive in a drawer at home is useless at 3 a.m. It belongs in the home's file, flagged on the front of the notes, and with the GP.
- Pair it with a documented goals-of-care conversation with the GP, covering the specific question: if she gets an infection, do we treat here or transfer?
- Advance Care Planning Australia runs a free national advisory service — 1300 208 582 — that will walk you and the home through the forms for your state.
The sentence to say to the facility: "I'd like to complete an Advance Care Directive and a goals-of-care plan for my mother with her GP. Can we schedule that?"
7. If she can no longer say
With no directive, decisions fall to the substitute decision-maker recognised in her state — and where none has been appointed, state law sets out who is asked, usually starting with a spouse or the person with the closest continuing relationship.
Note the framing: family members act as her voice, not their own. Which is why telling the clinician what she used to say — "she never wanted to be kept going on machines", "she'd want everything tried" — is not sentiment. It is the material the decision is built from.
8. If she does go
- Meet her at the ED if you possibly can.
- Send the medication chart, the directive and the home's contact with her.
- Tell the receiving staff immediately that she has dementia.
- Ask that restraint is avoided and that someone can stay.
- Push for discharge as soon as it is safe, and confirm the home is holding her place.
For the paperwork and for the search
If the 2 a.m. call happens because the home cannot treat anything on site and has no in-reach arrangement, then the problem is not that one night. It is the home.
Curalune Care Help (A$109) puts together, usually within 24 business hours, a shortlist of 3 to 5 homes matched to her area and care needs — with contacts and the questions to ask about after-hours cover and in-reach arrangements.
*General information, not medical advice. In an emergency call 000. Every clinical decision belongs to the clinician who has assessed the person.*