When They Go Into Hospital: The Carer's Job on the Ward

A hospital admission looks like the moment the job is taken off you, and it is not. It is the moment the job changes into a different one, which is holding the only complete account of the person in the bed, and starting the discharge before anyone on the ward is ready to talk about it. The ward has known them for a day. You have known them for decades, and NICE and SCIE guideline NG27 puts that in writing: hospital and community multidisciplinary teams “should recognise the value of carers and families as an important source of knowledge about the person’s life and needs”¹.

My mother went back in nine days after she first came home, and I arrived at the ward with nothing except my handbag and a sense of relief so strong that I remember feeling ashamed of it. I had not brought her glasses. For two days she could not read the menu card, could not see who was talking to her, and was described in the notes as vague. She was not vague. She could not see. That is the smallest possible example of the thing this article is about, which is that the ward cannot know what it has not been told.

If you have arrived here at the very start, caring for a parent at home is the map of the whole job, and coming home from hospital is the other half of this page, the discharge itself.

What is my job while they are on the ward?

Three things: be the record, be the translator, and start the discharge. Nothing else on the list matters as much, and everything else is optional.

Being the record means that you hold the baseline. What they were like a fortnight ago, how far they could walk, whether they normally know the day, what they normally eat, which words they use for pain. Clinicians on a ward see a snapshot and have to guess at the film. You have the film. Spotting when someone is getting worse is built on the same idea at home, and the value of it doubles on a ward where nobody has met them before.

Being the translator runs both ways. You translate them to the ward, particularly if they are deaf, quiet, proud, or the sort of person who tells a doctor they are fine because they were raised not to make a fuss. And you translate the ward to them, and to the rest of the family, which is mostly a matter of writing down what was actually said rather than what everybody hoped was said.

Starting the discharge is the part carers leave until somebody mentions a date, and by then it is too late to arrange anything. More on that below.

What should I bring in, and what should I put on one page?

Bring the four things that decide whether they can take part in their own care, and write one page that nobody has to ask you for.

The four things are glasses, hearing aids with batteries that work, dentures, and whatever they walk with. Somebody who cannot see, cannot hear, cannot chew and cannot get to the toilet unaided is not the same patient as the one who arrived, and the difference will be recorded as their condition rather than as a missing bag of equipment.

Then the page. One side of A4, handed to the nurse in charge and not left in the bedside locker:

• What they are normally like. Whether they know the day, whether they live alone, how far they walk and with what, what they can do for themselves. This is the sentence that turns a later change into a finding rather than a personality.
• What they take. Everything, including the tablets somebody buys at the chemist and the ones in the drawer that were stopped. The practical business of running a medication round is in managing someone else’s medication.
• What they cannot tell you themselves. Deafness, poor English under stress, a habit of saying yes to everything, pain they will not report.
• What frightens or settles them, which sounds soft and is the single most useful line on the page at three in the morning.
• Your name, your relationship, and a number that is answered.

Keep a copy. It becomes the first page of the care file, and you will hand over some version of it for years.

Why do people come out of hospital less able than they went in?

Because three things happen on wards to older people that have nothing to do with why they were admitted: delirium, deconditioning and falls. Knowing the names is what lets you raise them.

Delirium. New confusion in hospital is usually delirium and not the beginning of dementia. NICE guideline CG103 records that the prevalence of delirium in people on medical wards is about 20 to 30 percent, and that 10 to 50 percent of people having surgery develop it². It has an acute onset and a fluctuating course and usually develops over one to two days². CG103 also says something carers should hold on to: it is a serious condition associated with poor outcomes, “however, it can be prevented and treated if dealt with urgently”². The version that gets missed is the quiet one, and the guideline tells clinicians to be particularly vigilant for changes that may indicate hypoactive delirium, “which are often missed, such as withdrawal, slow responses, reduced mobility and movement, worsened concentration and reduced appetite”². In some settings it is very common indeed: SIGN 157 puts it at up to 50 percent of people who have had a hip fracture, and up to 75 percent in intensive care³. If you think you are seeing it, say the word delirium to a nurse, say when it started, and say what they were like before. Delirium or dementia sets out the distinction in full.

Deconditioning. A person who spends most of a fortnight in a bed loses strength and confidence in a way that is not obvious until they try to stand at home. The counter to it is unglamorous: their own shoes rather than slippers, sitting out for meals if the team agrees it is safe, walking to the day room rather than being wheeled, and asking whether the physiotherapist has seen them. Ask, do not assume. Moving someone safely covers the part you will be doing afterwards.

Falls. Somebody weaker than usual, in an unfamiliar room, at night, sometimes on new medicines, is at obvious risk. NICE guideline NG249, published in April 2025, records that around a third of people aged 65 and over and around a half of people aged 80 and over fall at least once a year, and that the one-year mortality rate after a hip fracture is 31 percent⁴. Ask what has been put in place, and mention any fall at home in the months before, because that history often does not travel with the ambulance. Falls at home is the fuller version.

The fourth thing, quieter than any of them, is eating and drinking. Meals arrive and are taken away, and nobody is counting unless somebody says out loud that this person needs help to eat. See eating, drinking and weight loss.

How do I stay part of the decisions when the patient is not me?

By getting consent said out loud early, and by understanding that capacity is decided one decision at a time rather than once and for all.

If the person has capacity, information is shared with you because they agree to it. So ask them, in front of a nurse, to say that they are happy for you to be told things and included in conversations, and ask for that to go in the notes with a phone number. It takes a minute on a good day and is impossible on a bad one, which is why it is a day-one job.

Where capacity is in doubt, the framework has a name in most systems. In England and Wales the Mental Capacity Act 2005 sets out that capacity is presumed, that it is assessed for a particular decision at a particular time, that a person is not to be treated as unable to decide merely because the decision looks unwise, and that anything done for someone who lacks capacity must be in their best interests⁵. Ireland’s Assisted Decision-Making (Capacity) Act 2015 works on the same principles and replaced the old wardship system with tiers of decision support⁶. In the United States, Canada and Australia the equivalents are state, provincial and territory instruments and the vocabulary changes, but the questions to ask do not: who decides, on what basis, and what does the person themselves want. Power of attorney and decisions covers the paperwork that makes this straightforward instead of frantic, and it is much easier to arrange before an admission than during one.

Being included is not the same as being heard, which is a separate skill. NICE has a whole guideline on shared decision making, NG197, and its existence is a useful thing to point at when a conversation is happening around somebody rather than with them⁷. Being heard in appointments is the practical method: one page, three questions, and the willingness to ask the same one twice.

When does the discharge conversation start, and who starts it?

About day two, and usually you. Ask who is coordinating the discharge. NG27 requires hospitals to make a single health or social care practitioner responsible for coordinating the person’s discharge, and says that person is the central point of contact for practitioners, the person and their family during discharge planning¹. Get the name and write it down.

Two sentences from the same guideline are worth having ready. Where a discharge plan relies on family or carers, the team must take account of their willingness and ability to provide support, their circumstances, needs and aspirations and their need for respite¹. And: “Ensure that people do not have to make decisions about long-term residential or nursing care while they are in crisis”¹. If you can only manage part of what is being assumed, say the whole truth in the first week and ask for it to be recorded.

Ask for the assessments now rather than later, because the mechanism in every system is that an assessment produces an entitlement and the assessment is usually triggered by somebody asking. In England and Wales, section 10 of the Care Act 2014 requires the local authority to carry out a carer’s assessment where somebody provides or intends to provide care and appears to have any level of need for support⁸. In the United States, ask the hospital’s discharge planner or social worker what home health has been ordered, remembering that Medicare home health covers part-time or intermittent skilled nursing and therapy for somebody who is homebound and does not cover 24 hour care or custodial care alone⁹. In Australia, My Aged Care is the single entry point for the assessment that establishes eligibility¹⁰, and Carer Gateway is the parallel route for you, including planned and emergency respite¹¹. In Canada and Ireland the named service varies locally, so the question to ask is who assesses eligibility for home support here and how the referral is made. The care needs assessment, the carer’s assessment and getting help in cover the three of these in detail.

One number to take some of the fear out of the week after. In England, 14.7 percent of discharges in 2024/25 ended in an emergency readmission within 30 days, rising to 17.8 percent among people aged 75 and over (NHS England Digital, Compendium indicator I02040, published November 2025)¹². Roughly one in seven goes back. If it happens to you, it is not evidence that you failed.

What to raise the same day, and what to do at home

While they are on the ward, ask to speak to the nurse in charge today, not at the next visiting time, if:

• They are more confused than yesterday, or the confusion comes and goes. Use the word delirium, say when it started, and describe their baseline.
• They have become withdrawn, slow, or stopped eating, which is the quiet delirium that gets missed.
• They are in pain and cannot say so, or are agitated in a way that is new.
• They have had a fall on the ward, including one they got up from.
• Their glasses, hearing aids or dentures have gone missing, which is not a small administrative matter.
• A discharge date has appeared and none of the six things in coming home from hospital has been settled.

At home, before an admission or after one, ring the person’s own clinician the same day if they are more confused than yesterday, have fallen, have stopped eating or drinking, are unusually drowsy, have a fever, or have new or worsening pain. Their own clinician first, because they hold the notes and the baseline. If that is not reachable, that is NHS 111 in the United Kingdom, the out of hours GP service in Ireland, an urgent care center in the United States, healthdirect on 1800 022 222 in Australia, and the provincial health line on 811 in most of Canada.

Use the emergency number straight away if breathing changes suddenly, there is chest pain, one side goes weak, speech changes, they cannot be roused, or there is bleeding that will not stop: 999 or 112 in the United Kingdom and Ireland, 911 in the United States and Canada, 000 in Australia. Nothing on this page is a reason to wait until the morning.