As I am approaching or within the last year of life, care professionals should recognise this where possible and, if I choose, discuss it with me and those important to me.

Individuals likely to be approaching the last year of life should be proactively identified and offered the opportunity to discuss this with an appropriate care professional. Those important to the individual should be included in this discussion, if the mindividual wants this.

My needs and unique individual circumstances should be assessed by an appropriate care professional. This holistic assessment may include: physical, emotional, psychological, social, cultural, spiritual, religious, sexual and relational financial, practical, needs/ concerns.

An holistic assessment of the individual’s needs should be undertaken by an appropriate care professional applying a standardised approach.

My existing and on-going care should be planned with me and those important to me in a sensitive way. I will also be asked about my wishes for future care including organ and tissue donation and if I choose an Advance Care Plan will be written.

A person-centred plan of care should be formulated and agreed with the individual and those important to them, by appropriate care professionals. An opportunity for future care planning should also be provided.

All appropriate professionals and services involved in my care, planned
or in a crisis, should be able to access the information about me and my conditions electronically, should I choose to give my consent.

All appropriate relevant professionals, including those involved in crisis care, should be able to read, update and share electronic records of care plans and Advance Care Plans if consent has been given.

I should receive appropriate physical, emotional, psychological, social, cultural, spiritual, religious, financial, practical, and relational support, when I need it. This should be in the setting of my choice with all the appropriate care professionals informed of my needs and wishes.

Holistic care should be provided in the most appropriate setting (respecting the individual’s choice where possible), at the right time, ensuring all appropriate medication and equipment are available, with co-ordinated care providers involved.

The people that give me the most help and support should be identified and offered an assessment to support their needs in supporting me, if they so wish.

Informal identified carers will be recognised as being integral to care planning, delivery and review. They should be offered a carers assessment and their needs be agreed and supported, if they wish.

My care should be reviewed at the request of me or my carers and as my needs, preferences, or situation changes and the necessary adjustments made to plans.

Individuals and their carers should be reviewed as part of a standardised assessment, on request or as their needs, preferences or situation changes, to ensure the care being provided is needs led, with adjustments made as required. This will be reflected in the individualised care plan.

I should have an identified service/ team who will be my main point of contact and I shall be informed of who to call in a time of crisis. My plan of care should be available to me and those who require it, at all times; including at a time of crisis.

Individuals should know at all times who and how to contact services, especially in a time of crisis. Care plans should be available and accessible, and individuals should receive responsive care linked to their urgent care needs.

If I am likely to die in the coming days, care professionals should recognise this and, if I want, discuss it with me and those important to me with my consent where possible.

Where the possibility is identified that an individual is likely to die in the coming days, they should be assessed for possible reversible causes, before being recognised as dying. If appropriate, and in accordance with the individual’s wishes, the assessment should be discussed with the individual and those important to them.

When I am dying, I should be cared for with dignity and compassion in the place of my choice, where possible. My physical, emotional, psychological, social cultural, spiritual, religious, relational, financial, practical, and needs/concerns should be addressed in accordance with my wishes and as my needs change.

Individuals in the last days of life should be cared for in accordance with their wishes and supported by a holistic plan of care, tailored to that individual and those important to them.

When I die and in the hours after, I and those important to me, should be cared for and supported according to our wishes.

Individuals who have died, and those important to them, should be continued to be cared for in a sensitive, dignified and culturally appropriate way in accordance to their wishes.

Those identified as important to me should know how and where to access appropriate bereavement support following my death, if it is required.

Access to appropriate bereavement support at the point of need should be available and offered or directed to as necessary.

I should have access to Specialist level Palliative and End of Life Care in my place of care if I need their support, advice and care.

Specialist Level Palliative Care services should be available for face to face contact seven days a week across all settings, and advice should be available 24 hours a day. Inpatient specialist palliative care provision should be available to those requiring it, with admissions seven days a week.

Care services are in place and available to ensure that I will receive the right care, at the right time, in the right place delivered by a skilled and competent workforce.

Services should be available, accessible, equitable and responsive so that individuals can access appropriate services including:

Adequate provision of coordinated services, which are able to communicate effectively

A workforce who are knowledgeable, appropriately trained, competent and have the right qualities to support individuals ��

I would like to live within a community that feels safe and comfortable talking about death and dying. It should be a community that supports me, if I choose, and those close to me, as I approach the end of my life and die in that community.

The community should have support structures in place to actively encourage discussions about death and dying and encourage communities to support those dying in their community.

I would like to be given the opportunity to discuss and, if I wish, to participate in research and studies to benefit my own and others care.

All providers of care and support should promote the values of innovation, research, audit, evaluation and patient and family reported outcomes of care within their organisations. This will underpin evidence based, high quality and effective provision and delivery of care.