Standards › Standard 10 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HSP-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 10 (Hospice and Palliative Care), criterion 10.6
At a glance
- When a patient is dying, a written dying care plan is in place (HSP-FRM-005).
- Comfort measures and pain control are given as the plan sets.
- The family present is supported to stay and to take part in care.
- The plan is reviewed at each change in condition.
- Stop and get help straight away if: a dying patient has no written plan, or pain and comfort are not reviewed when the condition changes.
1. Purpose
To give dying patients a dignified, planned and comfortable death (10.6).
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
The last days of life need a clear plan, comfort measures and a dignified environment. Without a plan, care becomes improvised and the patient suffers.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead palliative clinician | Owns the dying care plan | Clinician |
| Nurse | Delivers the comfort plan and records it | 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. Plan.
- Write the dying care plan on HSP-FRM-005 as soon as the patient is recognised as dying.
Key point: Planned early.
Step 2. Comfort.
- Give comfort measures and pain control as the plan sets, and record each dose.
Key point: Comfort first.
Step 3. Review.
- Review the plan at each change in condition, and support the family present.
Key point: Reviewed at change.
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 |
|---|---|---|---|---|
| Dying patients with a written care plan | 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-005 | Dying care plan record | Record |
| CLN-FRM-003 | Individual care plan (existing, reused) | 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)