• Discuss the care plan with the patient, if possible, and the family, and explain what changes to expect in the patient’s condition. Sensitively explore wishes about organ and tissue donation where appropriate.
  • For patients not being cared for at home, ensure family members are aware of the care plan and that details of how and when to contact the family if the patient deteriorates or dies are recorded. For patients at home, ensure family and carers know who to contact if the patient deteriorates or dies.
  • Ensure that all health and social care professionals involved or who may become involved, for example out-of-hours community services or hospital at night team, are aware that the person is thought to be in the last days of life and have access to an up-to-date care plan.