I worked with the Macmillan palliative care team in my area in a clerical role, while they were part of the discharge planning, they were not the carers in the discharge plan , that was usually done with the district nursing team and possibly a care agency . Before the person is discharged you should have a team meeting of all the people who will be involved and hopefully they can help you get the answers you need. My team were more involved in pain relief and psychological support for the person and their family, but they could get other agencies in to help. Night sitting if required was provided by Marie Curie nurses. Not all areas are the same, so what happens in one health authority might not in another. I hope by now you have a plan put in place.