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Anticipatory care planning (ACP) helps people make informed choices about how and where they want to be treated and supported in the future. Health and care practitioners work with people and the people that matter to them to ensure the right thing is done at the right time by the right person to achieve the best outcome.
ACP puts people at the centre of the decision-making process about their health and care needs, it encourages people to have conversations about what matters to them. A plan can be started at any stage of a person’s care and is often suggested by their healthcare team. This can be after life events such as a hospital admission or a decline in health.
An ACP is a record of someone wishes. It should be created over time and reflect conversations between a resident, th...
An ACP is a record of someone wishes. It should be created over time and reflect conversations between a resident, the people that matter to them and the health care professionals that work with them.
The plan should include:
ACPs will include information about care at the end of life including where residents would like to be cared for and their wishes about different treatments including resuscitation. All these discussions should be had sensitively and with consideration and should include the people who the resident wishes to be there.
These discussions are really important; however we understand that some staff members might not always feel comfortable having them. Try not to overcomplicate the matter – we can often start conversations with a simple question like ‘what matters to you?’ or ‘how would you feel if you have to go to hospital?’ and we often find that residents are keen to discuss this, as are those who matter to them.
Anyone can change their mind, and as circumstances change, what is important to people might also change. This is why...
Anyone can change their mind, and as circumstances change, what is important to people might also change. This is why we think the most important part of the ACP process is the ongoing conversations with residents and the people that matter to them.
Final plans do not need to be made but recording the content of these discussions means these plans can be built on. We would expect that ACPs would be reviewed perhaps every 6 months at the time of the resident’s reviews.
During the Covid-19 pandemic it is as important as ever to have an ACP in place and to know what is important to residents if they become seriously unwell with Covid-19 or other serious illnesses.
There are different ways of recording ACPs and each care home may differ. However it is really important that this information is shared with your health and social care partners so that any treatment plans reflect people’s wishes. The easiest way to ensure that information can be accessed by everyone who needs it is to link with the GP who can update the Key Information Summary (KIS). This is an electronic record which NHS24, the Scottish Ambulance Service and hospitals can access.
To help transfer this information quickly and easily, all HSCPs in Greater Glasgow and Clyde use a 4 page ACP Summary to record ACP decisions. This mirrors the information on the KIS so GPs can if they wish quickly copy information to the KIS. It can be accessed either on Clinical Portal (specific ACP tab), or services can use an interactive PDF.
If you have access to Clinical Portal you can fill out the 4 page summary directly on there. Clinical Portal will automatically send the ACP to the GP and they can if they wish transfer the information to the KIS.
If you do not have access to Clinical Portal you can fill out this interactive PDF and email or post a copy to the GP as the GP is not making regular visits at the moment.
Remember, if any changes are made at the ACP review this information needs to be sent to the GP so they can update the KIS.
People’s wishes and the wishes of those that matter to them, must always be taken into account when deciding on t...
People’s wishes and the wishes of those that matter to them, must always be taken into account when deciding on treatment plans. By doing this you will make a plan specific to this individual and based on what is important for them.
During the Covid 19 pandemic many residents who live in a care home will choose to remain there if they become unwell. Their emphasis would be on their comfort and being in their own room looked after by staff member who know them well. However there will be some residents who may benefit from admission to hospital and would want to be transferred. If they do go into hospital it is important to send with them a copy of previous discussions and a DNACPR form if it is in place to ensure a smooth transition into secondary care
Some people will not have considered these topics before. It is important that you give them time and space to reflec...
Some people will not have considered these topics before. It is important that you give them time and space to reflect before having these conversations.
There are Information Guides that have been developed by EC4H to help prepare residents and the people that matter to them to talk about ACPs. It may be useful to have an introductory conversation with residents and the people that matter to them, explaining that you would like to have further conversations soon and in the meantime this is some information they can read through and think about.
It is important to involve everyone in these discussions, however if a resident does not have capacity to make these decisions, then it may not be appropriate to give them this information. In these cases we should make every attempt to involve friends, family and carers in order to agree what would be best for the resident and respect their wishes.
Information for Residents - (PDF)