What's an End of Life Care Plan?

An end of life care plan, developed by healthcare professionals, patients, and families, is designed to ensure that a person’s final days are managed according to their wishes, with a focus on comfort and dignity.

Sometimes called an Individualised Care Plan for the dying person or similar names, its a document used by healthcare organisations to guide the care of someone who is in the final stages of their life.

An end of life care plan, developed by healthcare professionals, patients, and families, is designed to ensure that a person’s final days are managed according to their wishes, with a focus on comfort and dignity.

Here’s a simple breakdown of what an end of life care plan is, why it’s used, and what it does:

What is an end of life care plan?

It’s a plan that is tailored specifically for an individual. It outlines what kind of care and treatment they want (or don’t want) as they approach the end of their life.

The plan is created with input from healthcare professionals, the patient, and often their family. It details things like pain management, comfort measures, and any specific wishes the person has about their care.

Why would you have one?

It helps ensure that the person’s preferences and values are respected. For example, if someone prefers to avoid aggressive treatments that might not improve their quality of life, the plan will clearly state that.

The focus is on keeping the person comfortable. This includes managing pain and other symptoms so that they can spend their remaining time as peacefully as possible.

What is it used for?

The plan acts as a roadmap for the medical team, making sure that every aspect of the patient’s care (physical, emotional, spiritual) is considered and managed according to their wishes. While it is not a legal document in the same way as a will, it helps to ensure that ethical decisions about the patient’s care are made in line with what the patient has chosen.

Who creates the plan?

Healthcare Professionals:
The team may include doctors (such as specialists or the patient’s general practitioner), nurses, and palliative care specialists. In some cases, other professionals like social workers, chaplains, or therapists may be involved to address all aspects of the patient’s well-being.

The patient and their family:
Whenever possible, the patient is involved in the discussions about their care. Their wishes and values are central to the plan. Family members or loved ones are also invited to participate so that everyone understands and agrees on the approach to care.

When is the plan created?

When the patient Is nearing the end of their life: The plan is usually developed when healthcare providers recognise that the patient is entering the final phase of life. This might be when curative treatments are no longer effective or when the focus shifts to managing symptoms and ensuring comfort.

After a care review or change in condition: Sometimes, the plan is put in place following a significant change in the patient’s health—such as a serious decline in condition or after a discussion about prognosis. This ensures that the care provided aligns with the patient’s current needs and wishes.

During Advance Care Planning discussions: In many cases, conversations about future care are part of routine planning, especially for patients with long-term or terminal illnesses. This allows the patient and their family to express their wishes well in advance, so the plan can be implemented when necessary.

Is it always called an end of life plan?

In different NHS settings, an End of Life Care Plan may be known by several different names. Some of the alternative terms include:

Individualised Care Plan for the Dying Person:
Emphasises that the plan is tailored specifically to the individual’s needs and wishes.

Palliative Care Plan:
Focuses on managing symptoms and ensuring comfort during the end-of-life phase, rather than on curative treatments.

Advance Care Plan:
Often used to describe a plan that sets out a person’s wishes for future care, including decisions about treatments they may or may not want.

Care of the Dying Patient Plan:
Highlights the plan’s role in managing the care of someone who is in the final stages of life.

End of Life Care Pathway:
Sometimes used to describe a more structured approach to managing care during the end-of-life phase.

These names generally refer to the same core idea: a plan designed to ensure that a dying person receives care that aligns with their values, needs, and wishes while focusing on comfort and quality of the final weeks, days and hours of their life.