🕊️ End of Life Planning

💷 How much is this worth to me?

While not directly tied to QOF, this template is vital for:

• Contractual Enhanced Services (e.g. palliative care LES)

• Personalised Care and Support Planning (PCSP)

• Reducing unplanned admissions

• Gold Standards Framework (GSF) documentation

• Meeting CQC and CCG expectations for proactive end of life care

Accurate and structured completion ensures patient wishes are respected and shared across care settings.

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📊 High-level overview of the specification requirements

The template covers:

• CPR and DNACPR status

• Preferred place of death

• Presence of an end of life care plan

• Legal documentation: ReSPECT, ADRT, LPA

• Consent for record sharing

• Conversations around prognosis, treatment plans, and future care

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📌 What do you need to know?

The template includes several detailed sections:

🩺 Local Enhanced Service Recording

• Document:

  • CPR status

  • Preferred place of death

  • Whether an end of life care plan exists

📚 Useful Resources (for clinician and patient)

• NICE End of Life guidance

• Opioid conversion chart

• Abbey Pain Scale

• GSF advance care planning resources

💬 Important Conversations and Consent

Tickboxes for:

• Consent to share End of Life Care Coordination (EoLCC) record

• Legal grounds for consent:

  • Best interest decision

  • LPA (Health & Welfare)

  • Patient or representative consent

• Withdrawal of consent

🧭 Future Planning Conversations

• Record if:

  • Patient does not wish to discuss prognosis

  • Relative informed or unaware

  • Patient lacks insight into prognosis

Provides linked resources (e.g. future care leaflet) to support communication.

📝 Care Planning and Legal Documentation

• Advance care decisions:

  • Free text or SNOMED-coded plan

• ReSPECT documentation (tick if completed)

• DNAR documentation:

  • Who completed the form

  • Cross-reference to original location if not in GP record

• ADRT:

  • Refusal of treatment and sustaining treatment (Mental Capacity Act)

  • Documented involvement of healthcare professionals

• LPA for Health and Welfare

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💡 Hints and Tips

• ReSPECT and DNAR forms must be accurately referenced if not originated by the GP

• Ensure any advance care decisions include clear physical location where documents are held

• Use this template proactively — don’t wait until final weeks of life

• Combine with frailty, cancer, or care home templates where appropriate

• Record every discussion, even if the patient is not yet ready to decide — this supports continuity and care planning