End Of Life Care And End Of Life Care Plan

Palliative care is a holistic approach that supports people living with life‑limiting illnesses by managing pain and other distressing symptoms while also addressing emotional, social and spiritual needs. It aims to improve quality of life for individuals and their families, helping them live as comfortably and fully as possible. Palliative care can begin at any stage of a serious illness and may be provided alongside other treatments. It focuses on personalised support, ensuring that care aligns with a person’s values, wishes and priorities while offering guidance and comfort to those close to them.

What is a good death?

Regardless of where and how people die, everyone is entitled to receive person-centred care, at a high quality. People often see the aim of end of life care as ensuring people’s comfort and that they have a ‘good death.’

A good death typically means the dying person was treated with compassion, dignity and respect, was kept clean, comfortable and in familiar surroundings with people important to them close by.

Essential to ensuring people have a good death, and experience as little distress and pain, as much comfort and joy as possible in their last months, days or years, is developing and documenting an end of life care plan.

End of life care plan

Person centred care planning is as important in end of life care as in any other form of health and care delivery. End of life care plans are not easy to create, difficult conversations will need to be had about difficult choices.

In addition to the common areas included in a care plan, an end of life care plan will often include additional areas such as their preferred care setting should their condition worsen, preferences for symptom management and care after death. Opportunities for discussion should continue so the plan can reflect changes in a person’s wishes or needs in their final days.

Some people will already have what is called an advance care plan, which typically include:

• priorities and preferences for care and treatment
• decisions about resuscitation
• views about how and where they would like to be looked
• after in their last days of life
• who they would like to have with them
• any spiritual or religious beliefs they would like to be considered
• who they would like to make decisions for them if they become unable to make them for themselves

A good end‑of‑life care plan should be person‑centred, clearly reflecting what matters most to the individual, while anticipating their physical, emotional and practical needs.

Nursing Times emphasises the importance of involving people in decisions about their care, ensuring their preferences for treatment, support and place of care are respected. Effective plans are holistic, regularly reviewed and adaptable as circumstances change. They also require sensitive communication, collaboration with multidisciplinary teams, and thoughtful inclusion of those close to the person. By grounding care planning in empathy, clarity and shared decision‑making, nurses can help ensure people approaching the end of life retain dignity, choice and comfort.

A study by Nursing Times from 2016 developed an effective Personalised Care Plan for the Last Days of Life, based on five priorities developed by the Leadership Alliance for Care of Dying People. These Five Priorities of Care of the Dying Person, can help shape your end of life care plan approach:

1. Recognise The possibility that a person may die within the coming days and hours is recognised and communicated clearly, decisions about care are made in accordance with the person’s needs and wishes, and these are reviewed and revised regularly
2. Communicate Sensitive communication takes place between staff and the person who is dying and those important to them.
3. Involve The dying person, and those identified as important to them, are involved in decisions about treatment and care
4. Support The people important to the dying person are listened to and their needs are respected
5. Plan and do Care is tailored to the individual and delivered with compassion – with an individual care plan in place

Meanwhile the Social Care Institute for Excellence identified the holistic assessment, as we’ve already discussed, as being essential to delivering the best end of life care.

Here is more guidance on end of life care for adults, available via NICE, the NHS and the Royal College of Nursing.

Using supportive tools can make a meaningful difference when planning end‑of‑life care. Access Care Planning helps teams create, review and update personalised care plans with greater ease, reducing time spent on paperwork so staff can focus on what truly matters - being present with the people they support.

By streamlining assessments and ensuring information is accurate and accessible, the software enables care homes, nursing homes, hospices and other providers to deliver more responsive, person‑centred care. Digital tools don’t replace the human touch, but they do give caregivers more space, clarity and confidence to provide compassionate support when it’s needed most.