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Anticipatory Care Plans

What You Need To Know

(To get more information click on the v next to each question)

Anticipatory Care Planning is about thinking ahead and understanding your health. It’s about knowing how to use servi...

Anticipatory Care Planning is about thinking ahead and understanding your health. It’s about knowing how to use services better and it helps you make choices about your future care.

This is a process and should involve ongoing conversations between you, the people that matter to you and the health care professionals involved in your care.

We will discuss what is important to you and what living well means to you. We will discuss what treatments you would like and which treatments you would not like. We will also discuss where you would prefer to have this treatment. We might discuss end of life care with you. By talking about all of these things we can all work together to make individual treatment plans that respect your wishes.

We can record the decisions made during these conversations in an Anticipatory Care Plan.

Having a record of your wishes can help in many ways. It can help you think about what is important to you and give ...

Having a record of your wishes can help in many ways.

It can help you think about what is important to you and give you an opportunity to share this information with the people who matter to you.

It can help the people who matter to you understand your wishes. This means that if they have to make decisions on your behalf, they can be confident that they are making the same choice as you would. If they are your welfare Power of Attorney, they may be legally responsible for making these decisions if you lack capacity. If you do not have a Power of Attorney they can still speak with members of your health care team to let them know what you would want, however your health care team have legal responsibility to make these decisions. 

It can help your health care team understand what is important to you so that they can work with you to make treatment plans that respect your wishes. If you no longer have capacity to make these decisions, then your health care team can use your ACP to make decisions that best reflect your wishes. 

It can help everyone by giving them an opportunity to have open and honest conversations with each other. It gives you and the people that matter to you and opportunity to ask any questions you may have. It also gives your health care team the opportunity to make sure that you understand what is happening with your care and work with you to make appropriate decisions.

ACP Conversations can cover a range of topics. We can use the word "DISCUSS" to help everyone remember the different ...

ACP Conversations can cover a range of topics. We can use the word "DISCUSS" to help everyone remember the different topics that are part of Anticipatory Care Planning.

It might not be appropriate to talk about all these things at once, and there might be some things that we never get to speak about. That is okay. Everyone can go at their own pace, and we will never force people to have a conversation they are uncomfortable with.

You do not need to speak about these topics in a particular order, so if it helps, you can start off with easier conversations and work your way up to the bigger issues.

 You can find a printable copy of this DISCUSS guide on our Resources Page.

 

What can we DISCUSS?

(To get more information click on the v next to each word)

We want to make sure that you understand everything that we are talking about. Please let us know if there is anythin...

We want to make sure that you understand everything that we are talking about. Please let us know if there is anything that would help you understand things more.


If you would like other people to be involved in these conversations please let us know. If there are people you would not like involved in these conversations please tell us.


You might also have someone who is your “Power of Attorney”. We would like to speak to them as well. There is more information about Power of Attorney on this website. 

You can talk to us about things we could do to help you, as well as things you might not like to happen. You can also...

You can talk to us about things we could do to help you, as well as things you might not like to happen. You can also talk to us about treatments that we don’t think would be good for you.

You can talk to us about what life is like just now for everyone. You can talk to us about any informal care or suppo...

You can talk to us about what life is like just now for everyone. You can talk to us about any informal care or support that you receive from other people. This might be things like shopping, making meals or providing personal care. It could also include emotional support.


You can talk to us about whether you give this type of support to anyone else. If you do then you might be a carer. This will help us all to make sure that plans are in place to support everyone if you become unwell or there is a change in circumstance.


If you would like to find out more about help and support available for carers in your local area call the Carers Information Line on 0141 353 6504. You can also find lots of information on this website on our Carers Pages.

Cardiopulmonary Resuscitation (CPR) is a process which tries to restart someone’s heart. In most cases it will not be...

Cardiopulmonary Resuscitation (CPR) is a process which tries to restart someone’s heart. In most cases it will not be successful. You can talk to us about whether this might be appropriate for you and how you feel about it.

You can find more information about CPR on the Anticipatory Care Planning pages. Scottish Government have also produced a leaflet to tell you more about CPR.

You can talk to us about what makes you happy and brings comfort. This might be things like religion or faith, but co...

You can talk to us about what makes you happy and brings comfort. This might be things like religion or faith, but could also involve how you like to spend your time and the “little things” that bring you joy.

You can talk to us about where you would like to receive care and treatment. This could be short or long term treatme...

You can talk to us about where you would like to receive care and treatment. This could be short or long term treatment. You can also talk to us about where you would like to receive end of life care. This might be at home, hospital, a hospice or a nursing or residential home.

You can talk to us about services that may already help you in your day to day life, or other services that could be ...

You can talk to us about services that may already help you in your day to day life, or other services that could be useful. This might be a clinical service like district nurses, or a social care service like homecare. It could also be support services like Carer Support Services or local community support.

  Everyone has the right to an ACP. ACPs are not legally binding and there is not one way to record these decisions...

 

Everyone has the right to an ACP.

ACPs are not legally binding and there is not one way to record these decisions. The most important part of the ACP process is having the conversations; however it makes things a lot easier if any decisions made in these conversations are written down. This means that everyone can refer back to the document if they have to make decisions in future.

There are lots of different documents that can help you think about what is important and give you space to record the decisions you make. Here are some examples:

 

My Anticipatory Care Plan – this booklet was made by Health Improvement Scotland. It asks different questions and helps you make a plan which has lots of detail.

You can download a PDF of the booklet, or find out more information about Health Improvement Scotland.

You can either print off the booklet or you can type your answers straight onto the PDF (just click on each box). If you type straight into the PDF then you can save it and even email it to the people that matter to you. This means that everyone knows the important information and can easily access it.

You can also change your answers at any time - just remember to send the new copy to everyone so that they have the most up to date copy.

There is also an app you can download which helps you record the most important parts of the booklet. If you have this then you will always have a copy of your plan close by.

If you need the booklet in a different language then please email [email protected] or call 0141 225 6999.

 

My Thinking Ahead and Making Plans booklet – this is a shorter booklet but still helps you to think about lots of important decisions.

This booklet is also available in Urdu and Punjabi. If you need the booklet in a different language then please email [email protected] 

 

These are just some suggestions and there will be other versions available. It is important that you can find tools that you like and you feel are useful and easy to use. Do some research and find the one that is right for you and the people that matter to you.

Start off by thinking about what matters to you and writing these thoughts down. Above you will find some example of ...

Start off by thinking about what matters to you and writing these thoughts down. Above you will find some example of tools which can help.

Now you need to share these with everyone who needs to know about your wishes.

If you already have health care teams working with you, they may have their own documents which they use to record summaries of these decisions. Speak to them and let them know you would like to talk about anticipatory care planning. You can share any plans you have created with them and they can record the key information on their systems.

Even if you don’t have a health care team working with you, we still think it would be a good idea to write down your wishes.  You can share these plans with anyone you would like to know this information. For example we would encourage you to speak to your GP to let them know any decisions you have made and ask them to update your file to reflect your wishes.

An ACP contains lots of different information. It will record what matters to you - who is important to you, where yo...

An ACP contains lots of different information. It will record what matters to you - who is important to you, where you would prefer to receive treatment if possible, and what treatment you would like or treatment you would not like. This information helps us to work with you to make any treatment plans, at any stage of your life.

It may also contain information about end of life care. This is an important part of the document as it will help us work with you to make appropriate treatment plans at the end of your life. We will talk to you about where you would prefer to be treated at the end of your life, who you would like to be with you and your thoughts about what treatments you would like or not like.

We may also talk about what you prefer to happen if your heart stops. Sometimes it may be appropriate to try CPR to try and restart your heart. However this process has its own risks and does not work very often. We might talk to you about completing a DNACPR form – this stands for “do not attempt cardiopulmonary resuscitation”.  If a DNACPR is in place this means that if your heart stops, health care professionals will not attempt to restart it. It does not mean that you would not receive other treatment or that we cannot provide care to make you as comfortable as possible.

A CPR conversation is a very small part of the ACP process, however it gives you and the people that matter to you a chance to talk about your wishes and ask the health care staff involved in your care any questions you might have. It also makes sure that everyone is aware of decisions that have been made.

Scottish Government have also produced a leaflet to tell you more about CPR.

Anticipatory Care Plans do not cost any money. All you need to do is have a conversation with those that matter to yo...

Anticipatory Care Plans do not cost any money. All you need to do is have a conversation with those that matter to you and make a record of your wishes. You should then speak to any health care professional involved in your care so they can make sure the key information is store in their records and shared with colleagues.

Last Updated: 03 July 2020