End-Of-Life Care Documentation: A Guide for Care Homes 

A standard daily-notes template is designed for continuity of routine care. End-of-life care is something different. In the final weeks, days, and hours of a resident's life, the pace of clinical change accelerates, the number of professionals involved increases, and the decisions being made carry significant weight - legally, clinically, and for the family. 

A GP may visit to review anticipatory medication. A community palliative care nurse may attend to assess symptom control. Family members may be present around the clock. Each of these interactions needs to be captured in a way that is legible, time-stamped, and accessible to the next professional who walks through the door. A generic care plan template, built around weekly reviews and standard activities of daily living, is not structured to hold that kind of information safely. 

End-of-life care involves a distinct set of documentation touchpoints: advance care planning documents (including ReSPECT forms and DNACPR decisions), Lasting Power of Attorney records, syringe driver and symptom-control charting, verification of expected death, care after death (sometimes called last offices), and family communication records. Each of these has its own evidentiary requirements. Treating them as footnotes within a general care plan creates gaps — and gaps, in this context, carry real consequences. 

The ReSPECT form, or Recommended Summary Plan for Emergency Care and Treatment, is one of the most important documents a care home can hold for a resident approaching the end of life. The ReSPECT process records a person's wishes, choices, and decisions should there be an emergency when they are unable to speak for themselves. It is completed through a conversation between the resident (where possible), their family or carers, and a registered clinician, and it captures both the resident's priorities and the clinical recommendations that follow from them. 

Critically, the ReSPECT form is a clinical record of agreed recommendations - it is not a legally binding document, but it carries significant weight in guiding emergency responses. When a resident deteriorates suddenly and an ambulance crew or out-of-hours GP arrives, a clearly completed and accessible ReSPECT form can prevent inappropriate resuscitation attempts that the resident would not have wanted. Without it, the default is intervention. 

The ReSPECT process is increasingly being adopted within health and care communities around the UK, and the Resuscitation Council UK provides national e-learning for care home staff. Version 3 of the form is more person-centred, containing more prompts for explicit clinical reasoning and clearer language, a meaningful improvement for homes working to document nuanced, person-specific wishes. 

For a care home, the practical documentation requirement is straightforward: the ReSPECT form should be completed, stored accessibly within the resident's care record, and reviewed whenever there is a significant change in the resident's condition. An Advance Care Plan can be used to record what is most important to the person and how they would like to be supported in an emergency or at the end of their life, and the ReSPECT form is the most widely used vehicle for that in England. 

A DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) decision is a specific clinical instruction about one intervention. 

A ReSPECT form is broader as it encompasses the resident's overall goals of care, their values and priorities, and the range of treatments that are or are not appropriate, of which CPR is one element. A resident may have a DNACPR decision recorded within their ReSPECT form, but the form itself captures far more than that single decision. 

When a resident can no longer communicate or make decisions for themselves, the question of who holds authority to make decisions on their behalf becomes urgent. A health and welfare Lasting Power of Attorney (LPA) is a legal document that allows an attorney to make welfare and healthcare decisions on behalf of the donor, but only when the donor lacks mental capacity to do so themselves. This can include decisions about medical treatment, care arrangements, and, if the LPA specifically grants this, life-sustaining treatment. 

A Health and Welfare LPA can only be used once the donor has lost mental capacity, meaning that for many care home residents, the LPA may already be active on admission. The care home's responsibility is to establish, at the point of admission and as part of ongoing care planning, whether a registered LPA exists, who the named attorney is, and what scope of decision-making authority they hold. 

Without this information clearly recorded, a home may find itself in a position where clinical decisions are being discussed with family members who have no legal authority to make them, or, conversely, where the person who does hold authority is not being consulted. Neither outcome serves the resident well. Attorneys must always act in the donor's best interests, and care home staff should be familiar with the LPA document itself, not simply rely on a family member's account of what it says. 

The LPA record should be held within the resident's care file, with a note of the attorney's contact details and the scope of their authority. Where no LPA exists and a resident lacks capacity, the home should be following the Mental Capacity Act's best-interests framework and documenting those decisions accordingly. 

As a resident moves into the final days of life, oral medication often becomes impractical. Swallowing may become difficult or sometimes impossible, and the priority shifts to maintaining comfort through continuous symptom management. A syringe driver, also called a continuous subcutaneous infusion (CSCI), delivers a continuous stable dose of medication via a pump through a line under the skin, typically over a 24-hour period. It allows medications for pain, breathlessness, nausea, and agitation to be administered without repeated injections. 

The documentation requirements for a syringe driver are distinct from a standard Medication Administration Record (MAR) sheet, and this distinction matters. Any individual with a syringe driver must have their medication and drug dosages reviewed at least once a day. That review needs to be recorded, including the symptom assessment that prompted any dose change, who made the decision, and when. Where breakthrough doses of medication are administered, those too must be documented with the time, dose, and the symptom being treated. 

Syringe drivers must only be set up by professionals who have received the relevant training, and it is important to monitor the syringe driver and the infusion site carefully to ensure there are no problems with the delivery of medications. Each monitoring check should be recorded, including the volume remaining in the syringe, the condition of the infusion site, and the resident's comfort level. 

The charting also needs to be visible to the full multi-professional team. A GP reviewing the resident remotely, or a community palliative care nurse visiting for the first time, needs to be able to see at a glance what is running, at what dose, and how the resident has been responding. A syringe driver chart that exists only in a paper folder at the nurses' station, inaccessible to a visiting clinician after a certain time, is a documentation gap with real clinical consequences. 
 

For more on medication management and electronic MAR systems in care homes, see our safer medication management hub. 

The death of a resident who has been deteriorating over days or weeks is, in clinical terms, an expected death. An expected death is the result of an acute or gradual deterioration in a resident’s health status, usually due to advanced progressive incurable disease - anticipated, expected, and predicted. Even so, it requires formal verification before any further steps can be taken. 

Verification of expected death is an important stage in the process for relatives and carers, until it has been performed, no further action can be taken with regard to the deceased. In a nursing care home, a trained and competent Registered Nurse can verify an expected death where a local policy supports this. The Care After Death: Registered Nurse Verification of Expected Adult Death (RNVoEAD) Guidance, updated by Hospice UK in May 2025, provides a framework for the timely verification of expected adult deaths by experienced registered nurses who have been assessed as competent. 

Hospice UK's position is that only nurses included on the Nursing and Midwifery Council register should undertake this role, given the wraparound care required at the point of death, including the discontinuation and safe disposal of medication and care of the bereaved. 

In residential care homes without a registered nurse on duty, the process for contacting a GP or out-of-hours service should be clearly documented in the home's policy. 

Verification of death should be performed in a timely manner - best practice suggests within 4 hours of death in a community setting. Delays cause distress to families and create practical difficulties. The documentation at this point should record the time of verification, the name and registration number of the verifying professional, the clinical findings, and confirmation that a DNACPR or ReSPECT form with DNACPR decision was in place. A valid DNACPR or ReSPECT form with DNACPR decision must be in place as a prerequisite for registered nurse verification, however This is not universally mandated across all UK settings; verification eligibility also depends on local policy, competence, and regulatory frameworks. 

The care given to a resident's body immediately after death - historically called ‘last offices’ and now more commonly referred to as care after death - is both a clinical and a human act. The term ‘care after death’ is used in place of ‘last offices’ and is more befitting of our multi-cultural society, reflecting the variety of tasks of care at the time of death, including supporting the family and those identified as being of most importance to the deceased. 

The need to give personalised, compassionate care does not end when the person has died but continues with care after death, including supporting friends and families into bereavement. Each death is a uniquely individual experience that reflects many aspects, the illness the person has experienced, their personal preferences, and the social, cultural, spiritual, and religious aspects of the person's life. Documentation of care after death should reflect this. It should record what was done, by whom, and when, including any specific cultural or religious practices observed, the condition of the body, and any property secured. 

This documentation matters for several reasons, as it provides a record of staff accountability. It gives families, if they ask, a clear account of how their relative was cared for. And in the event of a complaint or safeguarding review, it demonstrates that the home's duty of care extended to the final moments and beyond. 

There is a responsibility to ensure that the appropriate professional is called to verify the death, the GP practice is notified so they can arrange discussion with the Medical Examiner and the issuing of the Medical Certificate of Cause of Death, the deceased's dignity is maintained, and the property is secured. Each of these steps should appear in the record.

The administrative and human work that follows a resident's death is often underestimated as a documentation category. Yet this is frequently where family complaints originate because communication broke down, belongings were not returned promptly, or the family felt unsupported in the days that followed. 

Good documentation in this period includes a record of who was notified of the death and when, what information was given to the family about next steps (including registering the death and contacting a funeral director), and what bereavement support was offered or signposted. Where belongings are returned, a signed record of what was handed over protects both the family and the home. 

The need to give personalised, compassionate care does not end when the person has died but continues with care after death, including supporting friends and families into bereavement. Documenting that support, even briefly, demonstrates that the home understood this. It also creates a record that can be shared with a safeguarding reviewer or CQC inspector if questions are raised later. 

There is no single dedicated CQC standard for end-of-life care. Instead, end-of-life practice is assessed across several of the five key questions - Safe, Effective, Caring, and Responsive - and inspectors will look for evidence across all of them. 

Under the CQC's framework, inspectors ask how people are reassured that their pain and other symptoms will be assessed and managed effectively as they approach the end of their life, including having access to support from specialist palliative care professionals. This maps directly to the Safe and Effective domains: is symptom management timely, is it reviewed regularly, and is there evidence of specialist input where needed? 

Inspectors also ask how the service makes sure that it quickly identifies people in the last days of life whose condition may be unpredictable and change rapidly, and that people have rapid access to support, equipment, and medicines. This is a Responsive question, and it is answered, in large part, by documentation. A syringe driver chart that shows regular monitoring, a care record that captures the GP's visit and the palliative nurse's advice, an anticipatory medication record that shows the home had the right drugs in place before they were needed: these are the kinds of evidence that demonstrate responsiveness. 

The Caring domain is addressed through questions about how the service supports people's families, other people using the service, and staff when someone dies, and what arrangements are in place for making sure that the body of a person who has died is cared for in a culturally sensitive and dignified way. Both of these are documentation questions as much as practice questions. 

Digital care records, used well, address some of the most common documentation failures in end-of-life care: records that are incomplete because a staff member ran out of time, charts that are inaccessible to a visiting professional, or advance care planning documents that are stored in a paper file no one can locate at 3am. 

Structured digital documentation can reduce the risk of missed reviews by prompting staff at the right intervals. It gives visiting professionals shared, real-time visibility of the resident's current medication, recent observations, and documented wishes. And it preserves a clear, timestamped record that can be shared with the family or reviewed by CQC without the need to reconstruct events from handwritten notes. 

None of this substitutes for clinical judgement, human presence, or the quality of the conversations that happen at the bedside, however. A digital record is only as good as the care it reflects. But where the care is good, structured digital documentation ensures that goodness is visible - to families, to inspectors, and to the professionals who will care for the resident in the hours ahead.