At our hospital local audit and observed practices identified that individualised care plans were not consistently shaped around the Five Priorities for care. 1 We devised a change in clinical practice, developing an approach to individualised care planning and regular proactive symptom assessment for patients in the last days of life. A 'Guide to individualised care planning in the last days of life' was developed, whilst a 'Symptom Observation Chart' (SOC) was adapted with permission. 2 The

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... itiatives were piloted and successfully embedded on an Acute Admission Ward and then cascaded across elderly care and oncology, haematology, surgical oncology, renal and renal transplant wards. SOCs were audited to ensure the adherence to record keeping, observation frequency and management and escalation recommendations. Nursing care plans were audited to ensure that at least 1 care plan was structured around the Five Priorities for care1every 12 hours. 33 SOC's were audited. 946 active symptoms recorded. When a PRN medication was required, management standards (medication given in <30 mins) were adhered to on 61% of occasions. On 51 occasions a symptom did not improve after a single PRN medication. On 36% of occasions, escalation standards were adhered to and a doctor/palliative nurse was informed. The standard of staff completing at least 1 nursing care plan structured around the Five Priorities for care1 every 12 hours, was not met consistently. The audit highlights the challenges of implementing a change in clinical practice. Further education is required. Nonmedical interventions are an important component of symptom management (71% of active symptoms recorded were managed without medication). REFERENCES