End of life care: Recording and sharing the advance care plan
61. You must make a record of the discussion and of the decisions made. You should make sure that a record of the advance care plan is made available to the patient, and is shared with others involved in their care (provided that the patient agrees), so that everyone is clear about what has been agreed. (See also paragraphs 22-23 about working in teams and across service boundaries.) If a patient makes an advance refusal of treatment, you should encourage them to share this information with those close to them, with other doctors, and with key health and social care staff involved in their care.
62. You must bear in mind that advance care plans need to be reviewed and updated as the patient’s situation or views change.