Practice question

Advance care plans

When should I consider holding an advance care planning discussion with a patient?

When should I consider holding an advance care planning discussion with a patient?

Advance care plans (ACPs) are part of ‘a process of discussion between an individual and their care providers irrespective of discipline’ (Henry and Seymour 2008).

Nurses are expected to encourage people to share decisions about care

Several UK policy documents state that ACPs are necessary in improving end of life care (Department of Health, Social Services and Public Safety 2010, Scottish Government 2011, Welsh Government 2013, NHS England 2014). 

Encourage and empower

The Nursing and Midwifery Council (NMC) (2015) Code states that nurses must: ‘Encourage and empower people to share decisions about their treatment and care’, and must ‘respect the level to which people receiving care want to be involved in decisions about their health, wellbeing and care.’

These statements suggest that devising ACPs could be part of nurses’ professional role. It should be remembered, however, that ACPs are made voluntarily and are not legally binding. They are intended to guide healthcare professionals as they seek to ensure patients’ wishes for their future care are met. 

Ageing population

The UK has an ageing population. As life expectancy and the number of older people increases, it is likely that more people will have long-term conditions, such as diabetes or chronic obstructive pulmonary disease (Audit Scotland 2007).

ACPs that set out people’s preferred environment for end of life care may be beneficial. Seal (2007) found that only 30% of people had discussed end of life care preferences with loved ones and, in the 75 years and older group, the figure was only slightly higher at 45%. ACPs ensure that preferences are communicated to loved ones.


ACPs have commonly been initiated when there is anticipated deterioration in a patient’s condition over a period of weeks or months. However, there is evidence to suggest they should be held earlier in the disease trajectory, for example during annual long-term condition reviews or after unplanned hospital admissions. 

Clark et al (2014) found that 64% of 10,000 unplanned admissions to 25 acute hospitals in 2010 were of patients aged 65. Nearly one third (29%) died within 12 months of admission. 

ACPs should include (Henry and Seymour 2008):

  • Patients’ concerns, if any, about their health.
  • Their important values and/or personal goals for care.
  • Their understanding about their illnesses and prognoses, and preferences for types of care or treatment in the future.

With patients’ agreement, ACPs should be:

  • Documented, with a copy held by each patient.
  • Regularly reviewed.
  • Communicated to people involved in patients’ care.


ACPs, like person-centred care practices generally, depend on a shared understanding of what is of fundamental importance to patients, including their goals and preferences for care.

Nurses often have the greatest amount of contact with patients, and ACPs offer them opportunities to take the lead in end of life care.

Jacqueline Thompson is nurse consultant, older people, Dundee Health and Social Care Partnership

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