Introduction In End-Stage Renal Disease (ESRD), frailty correlates with higher mortality rates, increased hospitalisations, and diminished quality of life. Timely discussions regarding patients’ wishes and advance care plans (ACPs) are pivotal in improving end-of-life care and minimising unplanned admissions. Coordinate My Care (CMC), a digital NHS service, offers personalised ACPs and urgent care plans, ensuring 24/7 accessibility, especially in emergencies.

Aims This study aimed to: 1) Assess healthcare professionals’ awareness of CMC through a survey; 2) Determine the prevalence of existing CMC records in frail renal patients; 3) Evaluate current practices in the Renal Department regarding ACPs and palliative care; and 4) Analyse the quality of existing completed CMC records.

Methods A survey was sent to all healthcare professionals to ascertain if they had a CMC account. A total of 290 potential patients with ESRF were screened. Among these, 89 patients were identified with a clinical frailty score of 6 or higher. Electronic records were then retrospectively examined to extract pertinent information concerning CMC and ACP.

Results The survey garnered 25 responses, revealing that merely 20% of healthcare professionals had an active CMC account. Of the 89 studied patients, only 20 (22.5%) possessed an existing CMC record. Additionally, 9 patients (21.4%) had ACP discussions but lacked accompanying CMC records. Barriers to ACP discussions were seldom related to language or family resistance, with the majority of cases characterised by simply not being discussed. Existing CMC records exhibited suboptimal completion, with several sections either partially completed or left vacant.

Conclusion Enhancing ACP discussions and CMC integration in renal care is crucial. Routine frailty monitoring is vital for identifying high-risk patients. Elevated or deteriorating Clinical Frailty Scores should prompt clinical reviews and ACPs when necessary. Addressing ACP discussion barriers through workshops, multilingual resources, and improved awareness is essential for optimal implementation.