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End-of-life support plans

End-of-life support plans

Preparing for those final days and moments can be difficult for both the person who is unwell and for their loved ones, but planning appropriately for this difficult time can leave you feeling reassured that everything is taken care of and that all of your wishes will be carried out.

If you choose to have end-of-life care at home, our dedicated team will meet with both you and your family to create a support plan that is completed tailored around you, your wishes and your needs. That way, you can all work from the same agreed plan that is led by your preferences and choices, enabling you to pass away in a dignified and respectful way.


What is an end-of-life support plan?

support planAn end-of-life support plan is a document that contains everything about a customer that a carer will need to know when they are carrying out care in their property, including specific instructions during the last days before they have passed away and the days following their death.

The support plan is created during the customer’s initial assessment with a local care manager, and includes important details such as personal care, medication, nutrition & hydration needs and medical details.

Due to the nature of end-of-life care, support plans are flexible and can be altered when a customer reaches the last days of their life. For example, if a customer is unable to leave their bed or becomes nil by mouth, amendments can be made in order to reflect both the customer’s and their family’s wishes of keeping them as comfortable as possible.

As well as giving a carer clear directions for their customer’s care routines, an end-of-life support plan also acts as an agreement between the customer, their carer and also their family, enabling the customer’s wishes to be respected both before and after their death.


What goes into an end-of-life support plan?

Due to the sensitive nature of end-of-life care, a customer’s support plan has clear and informative directives that are agreed during the initial assessment that are carried through until the customer has passed away, and sometimes for days or weeks afterward. This may include specific instructions for the carer to carry out during the customer’s last moments and support for their family after they have passed away.

A care manager will create the support plan with the customer and often with family present, which covers the following areas:

Personal details – name, address, next of kin information and other health professionals involved, including their GP. This may also involve the details of their district nurse or contact from Marie Curie or a similar organisation that specialise in supporting those at the end of their life. Important documents such as Power of Attorney (POA) and Do Not Resuscitate (DNR) would also be included here.

All about me – information such as life history and future goals may be omitted here as it would not be relevant for end-of-life care. Other information such as interests, wishes and spiritual needs would be included, as it’s important to ensure the customer’s final requests are met. For example, they may have religious routines that they may want carried out before they pass, or they may wish to have certain loved ones present when they are in their last few hours of life. There may also be details here of what their wishes are for after they have passed away. For example, they may want care to continue for several days or weeks afterwards in order to assist their loved ones with household duties and emotional support.

Personal care – all aspects of personal care that they need to be carried out for them or that they need assistance with, such as toileting needs, getting dressed and help with washing or showering.

Mobility requirements – the amount of support required to mobilise safely at home. This could be help getting in and out of bed, hoisting or regular turning in bed.

Nutrition and hydration needs – this could initially be having meals prepared or administered via a PEG feeding tube or specific instructions of which foods they can eat, but may change to nil by mouth as the customer progresses into the final days or hours of life

Consent – signed consent from the customer that they are happy with the support plan and the service agreement. If the customer is unable to sign, their POA can do this on their behalf.


How Helping Hands can help with your end-of-life support plan

Broaching the topic of end-of-life care can be quite an upsetting notion to discuss, particularly with spouses or children. Although this is difficult, discussing your preferences can ensure that you spend your last days in comfort and in the knowledge that your final wishes will be adhered to.

Our care teams have experience in assisting those with end-of-life care, and are able to offer you and your family the appropriate support and guidance. From liaising with other organisations involved in your health care, providing specific clinical care related to your condition, to psychological support for both you and your loved ones – we’ll ensure that the right carer is assigned to you in both experience and personality, so that you get the practical and emotional care that suits you.

For those with complex care needs who are also receiving end-of-life care, we have a team of clinicians who oversee the support plan and delivery of care. This could include someone with a tracheostomy, stoma, catheter or PEG feeding tube. A clinical nurse would be responsible for liaising with the care manager and carer to ensure they have the correct procedures in place for the customer’s specific clinical needs. Samantha Atkins, regional clinical lead for the Central area, has over 10 years’ experience as a nurse, working with patients with long-term health conditions and those receiving end-of-life care. Find out more about Samantha here.

Carers from Helping Hands can support all of you during this distressing time – from the initial conversation about the practicalities of your care, to your final wishes and requirements during your last moments and those after. Whatever your support plan involves, we’ll ensure that you receive care in a dignified and respectful way and coordinated appropriately for seamless care.



Page reviewed by Samantha Atkins, Regional Clinical Lead on February 27, 2020

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