Quality statement 3: Assessment, care planning and review

Quality statement

People approaching the end of life are offered comprehensive holistic assessments in response to their changing needs and preferences, with the opportunity to discuss, develop and review a personalised care plan for current and future support and treatment.

Quality measure

Measures from End of life care strategy: quality markers and measures for end of life care (Department of Health 2009).

See also quality measures and national indicators for further information.

Process: Proportion of people identified as approaching the end of life whose records include a documented assessment and discussion of their physical, psychological, social, spiritual and cultural needs and preferences.

Numerator – the number of people in the denominator whose records include a documented assessment and discussion of their physical, psychological, social, spiritual and cultural needs and preferences.

Denominator – the number of people identified as approaching the end of life.

Outcome:

a) People approaching the end of life and their families and carers feel that the assessment process was a useful means to considering their needs and preferences, identifying next steps and securing appropriate services.

b) People approaching the end of life feel satisfied that they have been able to discuss, record and review their needs and preferences if they would like to do so.

See the overview for overarching outcomes.

What the quality statement means for each audience

Service providers ensure that systems are in place to ensure comprehensive holistic assessments are carried out with people identified as approaching the end of life, in response to their changing needs and preferences, with the opportunity to discuss, develop and review a personalised care plan for current and future support and treatment.

Health and social care professionals offer or contribute to comprehensive holistic assessments with people identified as approaching the end of life, in response to their changing needs and preferences, including giving them the opportunity to discuss, develop and review a personalised care plan for current and future support and treatment.

Commissioners ensure they commission services that carry out comprehensive holistic assessments with people identified as approaching the end of life, in response to their changing needs and preferences, which include the opportunity to discuss, develop and review a personalised care plan for current and future support and treatment.

People approaching the end of life are offered full assessments to ensure they are getting the best care and support for their circumstances. During these assessments, they have the opportunity to discuss their needs (for example, physical, psychological, social, spiritual and cultural needs) and preferences. This includes the opportunity to develop and review a care plan detailing their preferences for current and future support and treatment.

Source guidance

Department of Health quality markers and measures for end of life care top ten quality markers for providers 3 and 4; and markers and measures 1.10, 1.11, 1.12, 1.35, 1.37, 2.2, 2.7, 2.8, 3.4, 3.5, 3.15, 3.16, 4.3, 4.4, 4.5, 4.9, 4.10, 5.2, 5.3, 5.9, 5.10, 6.2, 6.3, 6.9, 6.10, 7.6, 8.4, 8.8, 9.5 and 10.3.

NICE cancer service guidance key recommendation 2 and recommendation 1.18.

Data source

Process: Local data collection. Office for National Statistics (ONS) National bereavement survey (VOICES) includes questions on whether the person who has died was involved in decisions about their care and whether healthcare staff had a record of where the person would have liked to have died. The National care of the dying audit – hospitals may be relevant. The draft End of life care locality register pilot programme core dataset from the Information Standards Board includes preferences such as who else the person would like involved in decisions, preferences for place of death, 'do not attempt cardiopulmonary resuscitation' (DNACPR) request, Legal Advance Decision treatment refusal documents and details of any identified Lasting Power of Attorney. The comprehensive dataset also records religion or spiritual beliefs, whether the person has any special requests or preferences, whether there is anything in particular that they wish (ideally) to avoid, whether resuscitation has been discussed with them or their family and whether they have expressed a wish for organ or tissue donation.

Outcome: a) and b) Local datacollection.

Definitions

A 'holistic' assessment includes, as a minimum, physical, psychological, social, spiritual, cultural, and where appropriate, environmental considerations. This may relate to needs and preferences as well as associated treatment, care and support.

Personalised care plans may also be known as personalised 'support' plans.

A comprehensive assessment is likely to be multidisciplinary and may require the input of both health and social care professionals, as well as other appropriate support services. A comprehensive assessment is one that is coordinated effectively in order to avoid duplication.

All assessments and related care planning should be carried out in a sensitive way and in the best interests of the person approaching the end of life, with appropriate consent. Discussion about the value of the assessment process and what the person and their families and carers can expect should be offered.

The following description of assessment is adapted from the NICE cancer service guidance:

Assessments should encompass all aspects of end of life care, taking into account the preferences of the person approaching the end of life, and their families and carers, with respect to:

  • written and other forms of information

  • face-to-face communication

  • involvement in decision-making

  • control of physical symptoms

  • psychological support

  • social support

  • spiritual support

  • organ and tissue donation.

Once people have been identified as approaching the end of life, they should receive a prompt initial holistic assessment. Assessment should be an ongoing and proactive process that is both planned and responsive. Timing of assessments should take into account changes in the person's condition or circumstances as well as specific requests from the person approaching the end of life and their families and carers.

Holistic common assessment guidance from the National End of Life Care Programme provides information on assessment during the last year of life.

Information about personalised care plans, which may or may not include advance statements or advance decisions to refuse treatment depending on the person's preferences, is available from the National End of Life Care Programme in Capacity, care planning and advance care planning in life limiting illness: A guide for health and social care staff.

A guide to person-centred care planning in adult social care is available from the Department of Health.