A care plan is something we've done together, me and the patient,

where we've assessed what problems they see are their problems

and we plan together to make goals, to achieve these goals

and how we're going to help them feel better

about their long-term condition that they've got

and how to live with it better and maybe how to manage it better.

And a care plan gives them confidence

and control over their own condition.

It would include emergency contact numbers for a patient

for when they're feeling unwell.

It also includes their medication,

what to take and when to take it and how to take it.

They're very individualised, are care plans,

so some care plans may include information about diet and exercise

tailored to that patient's individual needs.

I think the care plan's very good.

As long as it keeps me out of the hospital.

Cath just takes my blood pressure and my oxygen levels and...

Well, she does me over in general.

COPD, which is chronic obstructive pulmonary disease,

affects Gladys' breathing.

The care plan involves looking at what Gladys can do when she's well

and recognising in herself when she's unwell

and what symptoms she recognises

and what to do when she gets those symptoms.

Since I've got Cath I know that Cath will look after me

and I feel more confidence in myself while I've got Cath.

I wouldn't feel at all happy if I didn't have her.

Gladys lives alone and has recently had a hospital admission with COPD

because her condition is deteriorating now.

One of the things I want to talk to you about

is recognising exacerbation of your COPD that you've got.


This'll be a sheet that's kept in your folder

and it talks about what an exacerbation is

and it means that it's two of the following.

Either more breathless than normal

or you're producing more sputum than normal

or your sputum's changed more green or yellow.

And if you've got two of those things it then tells you what you should do.

So that would mean increasing your inhaler,

using it more through the day...

Care planning involves giving the patient

information about their condition

so that they can take more control of their condition

to avoid maybe an unnecessary hospital admission

or becoming very unwell at home.

The patient will identify with us what they think their main problems are,

and that might be different to what a health professional thinks they are.

So it's about finding out what the patient likes to do, wants to do

and what they understand already.

Up to now my brain's all right.

Even if other parts are worn out.

It's all right if I can do the deciding what's happening.

I like to control my own life.

The care plan forms part

of the confidential medical records for the patient

and it's reviewed on a continuous basis with the patient,

maybe when the patient's condition changes

or the circumstances change.

You recognise when you're getting one of these exacerbations, don't you?

I think what we can do is have the steroids

and the extra antibiotics in the house for you

so that when you recognise that this is coming on

you can start taking them straightaway before it becomes too bad.

You can always ring me and just say,

"I've got these symptoms."

"I'm thinking about starting my antibiotics and steroids."

"Do you think that's right?"

And I can just tell you over the phone

and within the next couple of days I'd come out and see you.

Our patients have got long-term conditions that cannot be cured

and we discuss with them their wishes

about what they want to happen when they come to the end of their life,

so it might be around choosing where to die,

a lot of patients choose to die at home,

and about who they want present.

We make sure that everybody who's involved with the patient's care

knows about this care planning,

including their GP and the out-of-hours GPs,

so that the patient gets what they wish for.

(Gladys) I don't want any ventilator or resuscitation.

I just want to be left to go.

I think it's everybody's right

that they decide themselves when they want to go.

I'm not frightened of death.

Because I think I'll meet all my family and friends

and everybody else that's gone before me.