The conversations resulted in a support plan that included an Advance Care Plan. Sarah and her family have a hard copy as well.
There is record of her assessed need, outcomes and allocation, which was agreed by the relevant professional.
Her Electronic Palliative Care Co-ordination Systems (EPaCCS) was updated, and it included her decisions on DNACPR (Do Not Attempt Cardio Pulmonary Resuscitation).
The working and not working, and Sarah’s outcomes were also useful for the commissioners to inform the ‘Working Together for Change’ process.