Care plan

Everyone with MND is affected differently, so ‘one size does not fit all’. A care plan must be developed with the individual and those close to them to ensure a comprehensive and appropriate plan of care is developed.

Due to the fact that MND progresses so rapidly, this plan needs to be reviewed regularly to respond to any changes. The plan may involve a number of organisations and should be co-ordinated by a key worker. This may be the person with MND or a relative.

Key points to creating a care plan and maintaining it are:
  • the wishes of the person with the condition are paramount
  • communication issues should not prevent an assessment of needs
  • a care plan should provide sufficient information to guide those involved in delivering care
  • it should be updated regularly as the condition progresses
  • a single point of contact for co-ordination of care should be established.

Culture and spirituality

Spiritual and cultural beliefs are a vital part of who a person is and may have an increased significance for the person and their loved ones when facing a life limiting illness. Each person will have cultural, spiritual and religious beliefs that will shape the care you give. You can address cultural and religious needs by communicating with people about what is important to them. Be mindful that:

  • for some people spirituality may be linked to a belief system and for others it may be about finding meaning in what is happening
  • having a conversation and listening to people will help you understand and meet their needs
  • you don’t need to share a person’s values to respect them
  • a person may have rituals that they may need you to support them with before or after death
  • you won’t know what’s important to people unless you ask them
  • it is not possible to provide all the answers and a person may need further support by referral to a specialist team.