This website is no longer being actively maintained. Some of the material has been moved and is now hosted on the the End of Life Care section on the NHS Wales Health Collaborative website. The full link is: https://collaborative.nhs.wales/implementation-groups/end-of-life-care/
Ongoing care plan
As part of the ongoing care plan:
- share information with out of hours care providers as appropriate
- ensure that there is a regular review mechanism in place – as a minimum review when patient moves to next estimated prognostic group
- clarify key worker responsible for implementing care plan
- consider specialist palliative care team referral :