27.2 Developing and actioning a care plan

ActionRationale

  1. 1.
    Explain the rationale for a personalized care plan (this should include the importance of the individual's perspective).
    To gain the consent, cooperation and feeling of ownership of the individual affected by cancer (Hughes et al. [125], E).
  2. 2.
    Resolve issues that lend themselves to discussion and/or sharing of information (simply allowing the person the opportunity and space to talk may, in itself, be sufficient to ameliorate any concerns).
    To empower the individual by helping him/her resolve issues unaided (Doyle and Henry [92], E).
  3. 3.
    For specific issues, prompt or encourage the individual to take a specific action him/herself to address his/her concern or lead to intervention by a healthcare professional.
    To empower the individual by guiding and supporting him/her to resolve issues by utilizing the resources that are available to him/her (supported self‐management) (Doyle and Henry [92], E).
  4. 4.
    For complex or specialist issues, make a referral to other members of the multiprofessional team.
    To enable a specialist assessment of need (Hughes et al. [125], C).
    To ensure the provision of specialist support and care (Hughes et al. [125], C).
  5. 5.
    Record all discussions and agreed action points.
    To ensure an accurate record of all discussion/decisions/actions.
    To clarify and confirm agreed actions (Doyle and Henry [92], C).
  6. 6.
    Provide the individual with a copy of their action plan.
    To empower the individual and encourage ownership of the care plan (Hughes et al. [125], C).
  7. 7.
    Share the action plan with other healthcare professionals as appropriate.
    To ensure continuity in provision of effective multidisciplinary support and care (Hughes et al. [125], C).