Everything you need to know about advance care planning

Advance care planning is a process of discussion and consultation designed to set out a clear plan that centres around a person’s future treatment and care to ensure it is in line with their wishes and priorities at a time when they are no longer able to make decisions for themselves. 

These wishes could include: 

• How a person wants to be cared for 

• Who is involved in this decision-making process 

• What treatments they don’t want in the future 

• Where they want to receive end of life care 

 

An advance care plan is developed with the person receiving care and ensures ahead of any loss of decision-making abilities that their wishes and preferences are respected and followed. The discussions take place between people and those important to them like family members as well as health and care professionals.   

Developing an advance care plan isn’t a one-time discussion. Instead, when done correctly, it is a process that takes place over several constructive and meaningful conversations that always allow for due consideration and respect for a person’s wishes and emotions at all times, because what a person might wish for their future care could change over weeks, months or even years. 

How is advance care planning different from general care planning? 
The key considerations 
What is the purpose of advance care planning and what are the benefits? 
Advance care planning for people with dementia 
Which features of mCare help to develop advance care plans? 

 

How is advance care planning different from general care planning? 

With advance care planning, the objective is to clearly state the future wishes of the individual being cared for, allowing them to make decisions about their type of care and medication. These decisions will then be adhered to even when the individual may not be able to communicate their wishes due to deterioration in their condition in the future.   

It is written either by the individual or after discussion with and consent of the person receiving care while they still have the capacity to understand, consider and make these decisions. It can be written with support of care professionals, relatives and carers, but ultimately it must reflect and outline the wishes of the person in question, and it cannot be written if the individual does not have the capacity to make the statements in the advance care plan.   

General care planning, however, focuses on current and continuing health. The main difference is that a general care plan can be written on behalf of an individual or in discussion with that individual, whereas an advance care plan cannot – an advance care plan cannot be written on behalf of an individual – it needs to be written in accordance with their wishes and requires their formal consent. Generally, a care plan is a way to monitor, track and report on the care that is being given to people in healthcare settings to ensure that person-centred care is being always provided.   

As technology improves, the advent of digital care planning systems has made this process even better because using a digital care planning system means that care can be logged in real-time and in more detail, and a much higher level of data is available for audits, reports, and continuing improvement of care provision.   

What are the differences in the objectives of advance and general care planning? 

The main objective of a general care plan is to provide care professionals with a plan of action and correct guidance as they care for an individual. A general care plan is usually a carers primary source of information when caring for a person and is used for the care of people either with or without the capacity to make their own decisions. 

Care plans are ongoing and address the immediate needs of a person as well as the long-term needs by using all available resources to anticipate future care provision.   

An advance care plan provides the carers with information on the individuals wishes and preferences which can be hugely beneficial if the person being cared for loses capacity to communicate, which can be common in individuals who suffer with dementia or degenerative long-term physical conditions.   

Where does advance care planning fit into general care planning? 

Because care plans generally use all information available about a person to try and gain a greater understanding of what care is needed immediately but also what might be needed in the future as any long-term degenerative conditions cause either physical or cognitive decline, or both, advance care plans can play a vital role in long-term decision making.   

Utilising any existing advance care plan can indicate preferences and wishes for a person receiving care and can determine best interests when they have lost the capacity to make decisions for themselves or express their preferences in care provision. For example, if a valid and applicable advance decision to refuse treatment or nomination of a Lasting Power of Attorney was made when a person still had capacity to do so, then these are binding and must be taken into consideration in care planning.  

Developing person-centred care plans is one of the most important aspects of care provision. By utilising digital care planning systems, like Person Centred Software’s mCare, care homes can ensure that the best possible care is being provided and reported on in real-time.   

 

The key considerations for advance care planning 

Key areas of discussion when developing an advance care plan could include:  

• An advance statement of wishes, preferences and what the person prioritises for their care.  

• An Advance Decision to Refuse Treatment  

• The nomination of a Lasting Power of Attorney for health and welfare who is legally empowered to make decisions on matters such as life sustaining treatment on behalf of the person if they are no longer able to make the decision. This depends on the level of authority granted by the person.  

• Treatment that is specific to the context of a situation, such as emergency care when someone is suddenly taken ill, treatment plans, treatment escalation plans, resuscitation decisions and more.   

It’s important to remember that an advance statement within the advance care plan is not legally binding but could be very useful to inform and guide decision making at a time when a person, through mental or physical incapacity or both, is no longer able to indicate what their preferences or wishes are.   

Sharing this information with family, friends and health and social care professionals means that they have a far greater understanding of what a person might want for their care in the future. 

 

What is the purpose of advance care planning and what are the benefits? 

Advance care planning means that the person receiving care has a greater sense of involvement in their future care and has the opportunity to reflect on and share what matters most to them in the process of care provision ahead of a time when they are no longer able to make decisions or indicate what their preferences and wishes are.   

An advance care plan can give a person more confidence that they have gained and maintained control of their lives and future care because they will be receiving care and treatment that is in line with what matters to them.   

Through these discussions, it is also possible for a person to gain an understanding of what treatments might or might not be possible or beneficial. And in the event of a sudden emergency, a person can be more confident that what matters most to them is taken into account as part of treatment decisions. 

Benefits for friends, family and carers 

It can be a difficult and emotional time for a family when their loved one is receiving care, whether it’s emergency treatment, end of life care, or whether they are going through the process of moving into a care home. Though health and social care services always strive to deliver the most person-centred care possible, it’s not always easy to alleviate or ease the emotions that friends, family or carers might be going through. But through the development of an advance care plan, families, carers and those important to the person can be more content and confident in the knowledge that their loved one had control and ownership of the process and was able to make what matters most to them known while they were able to do so.   

It also means that a person’s loved ones will be less likely to have to contribute to decisions on behalf of the person without the person’s needs or preferences being explored and clearly mapped out in advance. This can be beneficial because it relieves the burden of responsibility in decision-making and reduces the risk of tension between family members who might disagree over what is best for their loved one at an already difficult time.   

Benefits for health and care workers 

For those caring for a person, advance care planning can provide greater satisfaction in their person-centred care because they too can be confident that the care they are providing is in line with the person’s wishes and preferences.   

It can also provide a greater insight into a person’s views and beliefs as well as reducing any risk of doing something that the person would not want or delivering care in a way that they would not wish. This can also be very beneficial in the process of developing a general care plan. 

Not only is this beneficial for the care staff, but it can also work to build relationships and reduce any possible tension between health and care workers and family members due to disagreements around the care and treatment being provided. Advance care plans can also work to reduce any conflict or tension between different care teams, who might otherwise disagree on the best course of action when delivering care.   

An advance care plan is a very useful tool in ensuring that the best possible person-centred care is always provided. Ultimately, it is a way for someone to consider, discuss and decide upon what means and measures of treatment best correspond to their wishes and beliefs.   

 

Advance care planning for people with dementia   

Making decisions in the short term that can better inform care in the long term is critical, and this is especially true in care residents with dementia. Advance care planning is a great benefit for a person with dementia because it gives them the opportunity to make their preferences for future care known at a time when they are still able to.   

Even those closest to someone might not have considered all the eventualities of care for their loved one, especially in an emergency, and it can be distressing for someone to have to make a decision on behalf of their loved one without fully knowing what it is they would want. An advance care plan can greatly reduce the impact of issues like these because it gives family and carers the knowledge to make more informed decisions on their loved one’s behalf.   

Advance statements and dementia 

One of the key areas of consideration for advance care planning for people with dementia is making an advance statement. An advance statement gives a person the opportunity to clearly define their preferences for future care once they are no longer able to either make decisions for themselves or able to indicate what they want, which makes it key in long-term dementia care. It also means that it is important for people with dementia to conduct an advance care statement, as well as an advance care plan, as soon after their diagnosis as possible.   

An advance statement can come in the form of a list of statements and could include things like wanting to stay at home as long as possible, who to involve in decision-making, and who not to involve, spiritual or ethical considerations for care provision, and others. An advance statement is not legally binding, but where possible it should always be considered and complied with.   

The benefit of advance statements for those caring for people with dementia 

By using an advance statement, care staff have the ability to anticipate the preferences and wishes of a person in the later stages of dementia at a time when they might not fully understand what they initially wanted. Through an advance statement, they can have the opportunity to better understand a person’s values, and this provides vital ongoing opportunities to enhance the choice and control an individual has over their treatment and care needs, or for someone making those choices on their behalf.  

It can help in the decision-making of care staff when it comes to best interests because in an advance statement, they have a measure by which they can qualify any changes to care asked for by the person in the later stages of dementia, and they can know, to the best of their abilities, they can provide the person-centred care that is in line with what the person wanted when they had the ability to clearly outline it. 

 

Which features of mCare help to develop advance care plans? 

By harnessing the features of Person Centred Software’s digital care planning system (mCare) which is part of the Connected Care Platform, care staff have the tools they need to ensure that advance care plans aren’t just properly undertaken and developed but are recorded and assimilated into a person’s wider care plan.   

Here are just some of the features of mCare that help with advance care plans: 

Who I Am

The goal of truly person-centred care is utilising all the data and information at hand to build a rounded picture of someone’s wishes, needs, values and life story, and the Who I Am feature within mCare helps to build just that.   

With Who I Am, care providers can create person-centred documents for each resident, uniquely tailored to them and comprising personal information that can help to specify care to a person’s individual needs and personality, and a part of Who I Am can include wishes for future care. Who I Am pulls through information from every area in the system and considers all preferences from various assessments.   

Not only that, but one of the great benefits of Who I Am and how it can be used to build an advance care plan is that the information is automatically drawn from a multitude of assessments; is not a manual process that relies on a person asking the right questions and remembering all the answers and tracking them correctly.

Assessment area  

If a care provider is looking to help a resident build an advance care plan, it can be difficult to know where to begin in order to capture not just the right information but all the relevant information that covers all possible eventualities ahead of a time when a person is no longer able to make their preferences and wishes known. But with Person Centred Software, you can find an advance care plan in the format of a form.  

Using specific forms in the system, which are found in the assessment area, care providers can help residents capture future wishes and preferences for care. Care staff can record whether a resident has a living will, a DNA CPR if relevant, as well as building a fully rounded picture of a person’s wishes for future care which include details like any additional requests around treatment, preferences around where they would like to be cared for and also religious or cultural preferences, among others.  

Action Plans  

Action Plans allows you to track actions within the digital care system, which provides a single, trackable solution for all of your action plans, coupled with a dashboard view that provides complete oversight of all actions needed to be taken. If there are specific actions that need to be taken within an advance care plan, such as anything to do with the transition to end of life care, then care staff can use Action Plans to create a specific action to ensure that this is done, evidenced and recorded.  

Visual representation of end-of-life stages  

mCare provides a complete and succinct overview of all residents that are receiving care, and one aspect of this that care providers can use to identify when actions might need to be taken with regards to advance care plans is the visual representation for the different stages of end-of-life care. 

On a resident’s file, there is an option to select different stages of end-of-life care, which are delineated by a butterfly that appears on their profile photo. Each stage has a different colour that defines which stage a resident is at, which allows carers to quickly and efficiently be aware not only that a resident is receiving end of life care, but what actions might need to be taken from the advance care plan now that this stage has been arrived at.

 

mCare gives you the tools to provide better care  

Ultimately, advance care plans, like general care plans, are a fundamental part of the process of providing truly person-centred care to those living in care settings.  

Person Centred Software’s digital care planning system, mCare, ensures through the features listed above and more that a person can not only ensure that their wishes and preferences stated in an advance care plan are understood and recorded, but that they are carried out.

 

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