Everything you need to know about advance care planning

What is 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 themself. These wishes could include how a person wants to be cared for, what treatments they don’t want in the future, or 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. 

An ongoing process

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 the their future care could change over weeks, months or even years.

With regular reviews and discussions, one of the main goals of an advance care plan is to reflect what a person’s wishes for care are up to the point that they can no longer specify this themselves, for example if their decision-making abilities are impaired due to dementia. 

Read more here about advance care planning for people with dementia

The key considerations

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 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. (Read more here about the differences between advance care planning and general care planning, and how they fit together).  

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.  

The importance of good care planning

Care planning is an essential component of providing care, and Person Centred Software’s digital care planning system, mCare, ensures that this process is as streamlined, as efficient, and as person centred as possible.  

Click here to find out more about mCare.