Advanced care planning

“Our ultimate goal, after all, is not a good death but a good life to the very end.”

― Atul Gawande, Being Mortal: Medicine and What Matters in the End

This resource aims to raise the profile of the value of advance care planning and to encourage nurses to develop their confidence in initiating conversations with patients as the opportunity arises in their day to day work.

The value of Advance Care Planning has been increasingly recognised in recent years. The International Society of Advance Care Planning and End of Life define advance care planning as “a process of communication between individuals and healthcare agents to understand , reflect on discuss and plan for future healthcare decisions at a time when individuals are not able to make their own decisions.”

In very simple terms it is planning for end of life care and can be done at any stage in life from well to dying. Healthcare professionals should be encouraged to facilitate open and honest conversations, as early as possible on the patient journey that will incorporate patient/carer choices whilst maintaining realistic expectations. The person must have capacity. It is advocated by the General Medical Council (GMC 2010) and has been a key component within the Gold Standards Framework since its conception. More information about Mental Capacity can be found in the Mental Capacity Act 2005 for England, Wales and Northern Ireland, and for Scotland Adults with Incapacity Act 2000.

Coordinated advance care planning improves end of life care (Detering et al 2010) and is associated with improved quality of care at the end of life (Bischoff et al 2013). Previous experience of end of illness and life care will influence individual participation in the advance care planning process (Amjad 2014). However, there are challenges in the implementation of advance care planning and these are multi-factorial (Rhee et al 2013) with a need for all in health and social care to adopt a “thinking ahead” approach to care planning.

There are key points in a person’s life when it may be of particular benefit to consider advance care planning e.g. when someone is admitted to a care home.

Anticipatory Care Planning

Planning for situations we expect or anticipate may happen to patients with chronic conditions including mental health. Anticipatory Care Planning can reduce unplanned admissions (Baker et al 2012).

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