West Essex Frailty Pathway: Principles of End of Life Recognition Surprise question Add to register Advance Care Planning Discussions with patient involving relevant primary care/community teams Link worker assigned Care Plan written Including documenting PPC,PPD and DNAR All relevant agencies identified and information is shared Care is coordinated through coordination centre. Relevant fast track processes commenced for funding when required. Key worker acts as link to all agencies. Key worker can ensure care plans are updated. Care delivery including ; Providing support for last few weeks or days of life in accordance with PPC and PPD Care after death Bereavement support and follow up for families and carers. Single Point of Access (SPA) 08:00-21:00, Seven days a week Telephone: 01279 827524 Fax: 01279 827827 Email: sep-tr.SinglePointOfAccess@nhs.net