Planning and Coordination at the end of life

Discussions and planning with people about their preferences and choices about dying, are extremely sensitive. The process is a continous dialogue between the individual and those close to them. By improving the recording and communication of people’s wishes and preferences for their end of life care; where you need to plan for their general care, as well as anticipate needs for the future. These should then be recorded in a consistent way to support communication between teams. Planning a good death, helps to maintain quality of life till the end.

Mental Capacity and ‘best interest’ decisions

The capacity for an individual to make decisions towards the end of their life may be difficult. And by law you need to make every reasonable effort to try to support them to make decisions about the care. However, there may be a time when they lack the mental capacity to make these decisions, you need to look at what provisions, if any, that they have in place for another individual/s to take over this responsibility.


Your Responsibility 

You have a responsibility to provide accurate records and updating/amending these records and/or notifying an individual when a change needs to be made.

Even more crucial is that these records remain confidential, and should not be shared with others unless permission is given. For instances if family members request access to these records then you need to check they have permission to look at these.

What you should record

There is some core data that you need to record

1. Record creation* and amendment* dates

2. Planned review date*

3. Person’s details Name* (including preferred name) Date of birth* Address* (usual residence) NHS number Telephone contact details Gender (self-declared) Need for interpreter Preferred spoken language Disability*

4. Main informal carer

Name Telephone number Are they aware of the person’s prognosis?

5. GP details Name of usual GP* Practice name, address, telephone and fax numbers*

6. Key worker Name Telephone number

7. Formal carers involved in care Name Professional group Telephone number

8. Medical details Primary end of life care diagnosis* Other relevant end of life care diagnoses and clinical problems Allergies or adverse drug reactions*

9. Just in case box / anticipatory medicines Whether they have been prescribed Location of anticipatory medicines

10 End of life care tools in use Name of tools e.g. Gold Standards Framework, integrated care pathway, Preferred Priorities for Care

11 Advance statement Requests or preferences that have been stated

12 Preferred place of death 1st and 2nd choices

13 Do not attempt cardiopulmonary resuscitation (DNACPR) Whether a decision has been made, the decision, date of decision, date for review and location of documentation

14 Person has made an advance decision to refuse treatment (ADRT) Whether a decision has been made and the location of the documentation

15 Lasting Power of Attorney (LPA) for personal welfare? • without authority to make life-sustaining decisions • with authority to make life-sustaining decisions Name and contact details of LPA

16 Names and contact details of others (1 and 2) that the person wants to be involved in decisions about their care

17 Other relevant issues or preferences around provision of care?


If you need further information on record keeping then please refer to [xxx]