Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly

Advance Care Planning :

Good Quality Patient-centred End Of Life Care

The primary role of the doctor (medical practitioner) in end of life care is to facilitate the provision of good quality patient-centred care that emphasises continuous, open, informed communication and collaboration between the patient, the health care team, and, where appropriate, the patient’s carers, family members and/or substitute decision-maker.


Good quality end of life care should:


  • ensure the patient is always treated as an individual, with respect, dignity and compassion in a culturally sensitive manner


  • endeavour to meet the patient’s care needs and uphold their care preferences which should guide decision-making and planning


  • strive to ensure that the patient is free from suffering


  • endeavour to facilitate care in the patient’s environment of choice, where practical, recognising that a patient’s health care needs may change in the course of their condition


  • ensure that the patient’s goals and values for end of life care are respected


  • respect the patient’s privacy and confidentiality, even after death


  • support not only the physical needs of the patient but also the psychological,emotional, religious and spiritual needs of the patient and their family members and carers


  • empower patients and, where appropriate, their family members and carers toparticipate in managing their treatment


  • provide counselling and other support to patients, their family members and carers throughout the patient’s condition, including support for family members and carers beyond the patient’s death


  • ensure patients and their family members and carers have access to good quality palliative care resources such as educational materials as well as physical aids in a timely, easily accessible and coordinated manner


  • ecognise the role of doctors, allied health care professionals, carers and the wider community in working together to meet the needs of patients


  • facilitate continuity and coordination of care within and between medical, health and community services including when the patient transitions from medical care that is primarily focussed on curative treatments to care that is focussed on palliative treatments.


Death, dying and bereavement are all an integral part of life; however, reflecting on and discussing death can be profoundly confronting and difficult.

Open and frank discussion of death and dying including end of life care options, approach to futile treatment, caring and bereavement should be encouraged within the profession and in the wider community.


(AMA, 2014 )

End Of Life Care in the UK

The independent Review of the Liverpool Care Pathway highlighted some of the most difficult challenges faced by doctors, patients and everyone who wants to make good end of life care a reality for all patients.

More Care Less Pathway

Independent Review of the Liverpool Care Pathway. (2013)

view/access  PDF 496 KB

In response, the report by the Leadership Alliance for the Care of Dying People set out a number of ambitious goals for raising the standard of practice in end of life care, including improving the education and training of healthcare staff.

One Chance To Get It Right

Improving people’s experience of care in the last few days and hours of life.

Leadership Alliance for the Care of Dying People, 2014

view/access  PDF 1896 KB

Governments across the UK have made end of life care a priority and there is a recognition that improvements can and should be delivered over the next few years.


The Liverpool Care Pathway was replaced by :


five priorities for the care of dying people in England in 2013 :

  1. The possibility that a person may die within the coming days and hours is recognised and communicated clearly, decisions about care are made in accordance with the person’s needs and wishes, and these are reviewed and revised regularly.

  2. Sensitive communication takes place between staff and the person who is dying and  those important to them.

  3. The dying person, and those identified as important to them, are involved in decisions about treatment and care.

  4. The people important to the dying person are listened to and their needs are respected.

  5. Care is tailored to the individual and delivered with compassion – with an individual care plan in place


and five core principles for end of life care in Northern Ireland in July 2014 :

  1. There should be timely identification that a person is dying and is probably in the final days and hours of life.

  2. Sensitive and clear communication should be at the centre of quality care.

  3. People who are identified as dying should have their physical, psychological, spiritual and social needs identified and be involved in decisions about how those needs can best be met. The person’s needs should be regularly reviewed and re-assessed throughout the last days and hours of life.

  4. Care in the last days and hours of life should be planned and co-ordinated with a focus on symptom control, comfort management and ensuring that psychological, social and spiritual support is provided to meet the person’s needs.

  5. Support for family and carers should be provided during their loved one’s last days and into bereavement.

Scotland has the Strategic Framework for Action on Palliative and End of Life Care 2016–2021

Strategic Framework for Action on Palliative and End of Life Care 2016–2021

The Scottish Government, 2015

view/access  PDF 2161 KB

and Wales issued its end of life care delivery plan in December 2014

Together for Health - Delivering End of Life Care

A Delivery Plan up to 2016 for NHS Wales and its Partners

The highest standard of care for everyone at the end of life, 2013

view/access  PDF 172 KB

Together for Health - End of Life Care Annual Report 2015

The Welsh Government

view/access  PDF 1013 KB

As of 2016 a number of specialist organisations will be working together, including General Medical Council, the Royal College of General Practitioners in Wales, NHS Education for Scotland, the National Council for Palliative Care and the National Gold Standards Framework Centre in End of Life Care, to address the need for better training.

Advance Care Planning, CGA based Proactive Primary Care of the Elderly

This topic is part of the Advance Care Planning domain of the

Comprehensive Geriatric Assessment

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doctor and patient

Advance Care Planning is one of 8 domains of the

Comprehensive Geriatric Assessment (CGA)

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