it is essential to obtain a written informed consent and include in the patient record. In addition it should be recorded that the patient and family/significant other (if appropriate) has received the written plan and understands the information. As with any plan it is not enough to just present or even just read and expect the patient and others just to sign. It is essential to include a frank, open discussion of elements, provide opportunities for questions and input into the plan. The plan may need discussion more than once Ideally the plan's components should be reviewed and revised as necessary with follow up visits to the health care providers.