Care planning

All people approaching the end of life need to have

• their needs assessed
• their wishes and preferences discussed
• an agreed set of actions reflecting the choices they make about their care recorded in a care plan.

The care plan can include a person’s general wishes and preferences about how they are cared for and where they would wish to die.

The care plan should be

• subject to review by the multidisciplinary team, the patient and carers as and when a person’s condition, or wishes, change
• available to all who have a legitimate reason to access it.

Some people may also want to make an Advance Decision to Refuse Treatment (ADRT)

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