Planning for the future
My End of Life Care Plan
The care I would prefer
My Name is
You can put your Picture/Photo
here
This document has been developed with the support of a small grant for adults with learning difficulties & adults with autistic spectrum disorders 2011 – 2012
from West Sussex County Council.
Our thanks also go to the Powerful Trainers organisation for their
help and support with this work, especially Georgina Littlechild,
Anthony Wake, Nicola Smith, John Warwick
Contents
1 Introduction
Someone may be needed to help with completing this form
2 About me
Personal details to be completed together with information on where more detailed information may be kept
3 My preferred place of care
This is where choices about the place of care during terminal illness can recorded
4 Who I would like to help care for me
This is where choices about which people you would like around you during your illness, who you would like to help with your personal care, who you would like to visit, including whether there are people you do not want to have around you or to give you care.
5 Where I would prefer to die
This is where choices about your preferred place of death can be recorded.
6 My funeral
This is where choices about the format of a funeral, for example, burial or cremation, music, which people you would like to attend your funeral
7 After my death
This is where preferences about where the your personal possessions can be recorded also information about your will and an other relevant documents can found.
8 Organ donation
This is where the person can say whether they wish there organs to donated after they die.
Introduction – How to complete the personal End of Life Plan
1This introduction goes through the stages of the end of life care plan. You may be asked by someone you know, or look after, for help with completing this plan. It is similar in format to the Health Assessment and can beattached at the back. It may be useful to complete the form in pencil first. 2 The plan sets out a number of choices, most of which require a yes or no answer in the form of a tick or cross.
3 The plan is aimed at helping the person choose the care they would like to receive at the end of their life and also those who they would like to care for them. It is important that this is a personal plan and can be completed
several years before a person expects to die.
5 It is important to record any information about anything the person would not like to happen to them or anyone they would not want to have caring for them.
4 The plan also allows the person to record where they would prefer to die. The choice in this section may change during the course of an illness and it is important to allow the person to regularly review their choice. It also has a space to record who they would like to care for them. It may be helpful to arrange for the person to visit the places where they could die.
Introduction – How to complete the end of life care plan
1. Find someone who knows you well and ask them to help you (for example keyworker, support worker, parent) – someone you want to help you with your end of life plan.
2. This plan is a record of your choices, look at each section and make your choice. There is an explanation for the person helping you alongside the information for you. Most of the choices can be answered with a
or a
Yes No
3. You can select your choices for the care you would like to be given towards the end of your life. This is your plan to share with those you live with or
who come to help you.
4. Where you would prefer to die. This is where you select the place you would like to be when you die. You can change your mind at any time and select somewhere different.
5 The plan allows the person to plan their funeral, or at least to choose between burial and cremation. What, if any music, they would like and even who they would like to be invited. It also records is the person has made a will and this may be an opportunity to discuss making a will.
6 It also has a section where the person can record what they would like to happen to their possessions.
If you have helped to complete this form it would useful if you could put your name and contact details in the form.
There may also be relatives and friends whose names should appear in the plan, this is particularly useful is the person were to become ill suddenly.
If this plan is being used on its own and is not attached to the health
assessment then it would be helpful to record the name and contact details of the GP.
5 What you would like to happen at your funeral. This is where you can record whether you would like to be buried or cremated and if there is any one special you would like to be present at your funeral.
6What you would like to happen to your belongings/possessions after your death
About Me
This is where personal details should be recorded. If the person has a Health Assessment book then this end of life care plan can be added to the existing information and very little additional personal information will be needed because it is already recorded in the health assessment.
If the person is known to have religious beliefs they should be recorded on this page. This space can also be used to record any spiritual beliefs or things which are special to them, for example if they like to listen certain music, have
favourite perfumes, would like certain objects about them.
People the person would like to know about this plan
There may be relatives or friends who the person would like to know that the plan exists. It is useful if the General Practitioner is one of these people. If the end of life care plan is kept with general Health Assessment Plan then if will be easily accessible. But it should be remembered that there may be people who the person does not want to know about the plan
2. About me
My name is ...
My date of birth is...
My phone number is...
I live at...
How I communicate...
My religion /belief is...
My place of worship is...
The People who have helped me with this plan are
Name... Name...
People I would like to know about this plan are
Name... Name...
I have made a will
Yes No
Put a circle round your choice
You can find my will at...
I would like to make a will
Preferred Place of Care
This is section where a person can record where they would like to be during the months before they die.
It is important that people look at this plan before they become too ill or enter the terminal phase of their illness. This section can be completed during a
health assessment meeting and be regularly reviewed throughout a person’s life. As they become increasingly ill or frail they may change their mind where they would like to be, so it is important to review this section and makes changes as required.
Although this will be a preferred place of care it is not always possible to stay for long periods in some of the places listed, for example a hospice.
3. My Preferred place of care when I am dying is
My HomeAdress………. ………
Another persons home
Adress……… ……… A care home Name………. ……….. A Hospice Name……….. ………. Hospital Name……… ……….. My preferred place of care is
somewhere else?
Address………. ………
Who I would like to care for me
This is where the person can list those people who are important to them. They may have some people they would like to help them with specific aspects of their care. There may be someone they would like to visit them to undertake specific tasks with them, for example reading to them or listening to music.
If they live in a community home they may have some preferred friends. It is important that these friends are prepared to give help and that they are helped to understand about their friend’s illness and their wishes.
If the person has identified special friends to help with particular areas of their care then this should be noted in the plan.
This is also the section where people can list their favourite pastimes, objects that are important to them.
They can also list what they do not want to happen and things and people the do not like or want to see during this part of their lives.
If someone has a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) form please note below where it can be found.
4 Who I would to care for me
I would like the following people to be involved in my care These can be family/friends or health or caring professionals
Family Nurse Friends Support worker
Name... Contact... Name... Contact... Name... Contact... Name... Contact... Name... Contact...
When I am being cared for these things are important to
me
Radio
Music
Books
Pets
Television
Reading or
People reading to me
Any other things
………
Things that someone may not want to happen to them when they are dying can include:
•
People they do not want to seeThings I do
not
want to happen when I am
dying
………
………..
……….
5. Where I would like to die
This is the section where people can list where the would prefer to be when they die, this may not be the same place as where they have been cared for during the last phase of their lives. Again this may change throughout the course of an illness and should be regularly reviewed.
There may be some things that the person does not want to happen to them during the time they are dying and these should be recorded in this section.
5 Where I would prefer to die
My Home
Adress………. ………
Another persons home
Adress……… ……… A care home Name………. ……….. A Hospice Name……….. ………. Hospital Name……… ……….. I would prefer to die
Where………. ………
My Funeral Plans
This is the section where people can indicate whether they would like to be buried or cremated and where they would like this to happen and who they would like to come to their funeral. Also what they would like to happen after their funeral.
6 My Funeral
When I die I would like to be buried
Yes No
Circle your choice
When I die I would like to be cremated
Yes No
Circle your choice
After my funeral I would like my friends and family to celebrate my life by……….. ………. ……….
This is how I would like the service to be
I would like this music...
I would like this to be read ...
This is the person I would like to take the funeral service
Name... Address... Telephone number...
I would like flowers at my funeral
Yes No Circle your choice
7 What the person would like to happen after their
death.
It is important that the person can identify what they would like to happen to their possessions and other belongings after the die.
8 Organ donation
This is gives the person the possibility to decide whether or not they would like to donate their organs to someone else after they die. Easy read information on organ donation can be found at
7 What I would like to happen to my belongings and
possessions
... ...
8 Organ donation
I would like to give parts of my body to Help others after I die:
Yes No Circle your choice
Details……… ………..
