Individual Plan of Care

Planning for the last days of life

When a patient is dying it is important to discuss their needs and wishes for the last days of life. Some patients will be able to discuss this themselves, but others may be too unwell or not have the capacity to do so. If the patient lacks capacity and is unable to participate in conversations then those people close to them should be involved in discussions and if appropriate, in making decisions in their best interests. It is important to ask if the patient has made or recorded any decisions in advance. They may have an advance decision to refuse treatment in place or may have appointed a lasting power of attorney. Some patients may previously have expressed wishes about where they would prefer to die. All decisions should be made in accordance with the principles of the Mental Capacity Act (2005).

An individual plan of care

Each patient who is recognised to be dying must have a plan for their care that considers their individual needs. The plan should be discussed openly with the person and those identified as important to them. The plan must be reviewed on a daily basis and altered if the patient’s needs have changed.

Documenting the plan of care

The ‘Individual Plan of Care for the Person in the Last Days and Hours of Life’ supports the documentation of care provided for a person in the last days and hours of life. It also contains a lot of useful guidance about things to consider when caring for a dying person.

Important things to consider within the plan

• Preferred place of death • Symptom management • Nutrition and hydration • Practical needs

• Social needs

• Psychological support • Family involvement and support • Spiritual needs • Cultural needs

• Religious beliefs