Standards › Standard 10 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HSP-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 10 (Hospice and Palliative Care), criterion 10.4
At a glance
- Family and carers are told about the illness, the plan and what to expect, in a language they understand.
- The family is given a named contact and the out-of-hours number.
- Support in the carer role is offered and recorded (HSP-FRM-003).
- Bereavement support is offered (HSP-SOP-005).
- Stop and get help straight away if: a family is not told about the plan or given no named contact when the patient is dying.
1. Purpose
To keep families informed and supported in their role (10.4).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Family and carers carry much of the burden of palliative care. Telling them what to expect, and supporting them, keeps the plan working at home and in the last days.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead palliative clinician | Gives the information and the plan | Clinician |
| Social worker or nurse | Offers carer support | Nurse |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Inform.
- Explain the illness, the plan and what to expect, and check understanding.
Key point: Understood, not just given.
Step 2. Name a contact.
- Give the named contact and the out-of-hours number.
Key point: A name and a number.
Step 3. Support.
- Offer carer support, and record the offer on HSP-FRM-003.
Key point: Offered and recorded.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Families with a named contact recorded | 100% | Monthly | Lead palliative clinician | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| HSP-FRM-003 | Family support and bereavement follow-up record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Palliative Care fact sheet and the Lancet Commission on the Global Access to Palliative Care and Pain Relief (2017). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)