End of Life Care Practice Development Team

Advance care plan

Advance Care Plan

Planning for your future care (advance care planning) gives you the opportunity to think about, talk about and write down your wishes, preferences and priorities for your care. This includes how you would like to be cared for towards the end of your life. You can include anything that is important to you, no matter how insignificant it may appear.

Advance care planning can help you and your carers (family, friends and professionals who are involved in your care) understand what is important to you. The plan helps you to discuss your views with those who are close to you. It will help you to be clear about the decisions you make and keep a written record of your wishes so that they can be carried out at the appropriate time. Recording your wishes and preferences for care helps to make sure that your wishes and preferences are taken into account. You can choose who you share this information with.

An advance care plan can be created at any time. It is a good way to make sure your wishes are recorded and allows a secure approach on life.

To help you with your planning we have created an 'Advance care plan' that you can fill in, dowload a copy here: Advance Care Planning (ACP) Booklet[pdf] 2MB or request a copy by contacting the PALS team on acp@nhft.nhs.uk or 0800 9178504.

For Easy Read information please see the below documents.

EASY READ - Advance Care Planning Booklet (ACP)[pdf] 3MB

Priorities for care of the dying person

The five priorities for care of the dying person help us to care for an individual thought to be in the last few days and hours of life. This method focuses on giving compassionate care.

Every member of staff has a duty to know and understand these priorities even if they don’t often come into contact with patients at the end of life.

1. Recognise

If someone's health unexpectedly gets worse we should consider if there is a cause that can be reversed. A doctor must assess if change can be reversed or if person is likely to die within a few hours or days.
If it may be reversed, take prompt action in line with the person’s wishes (or best interests, if they lack mental capacity).
If they are likely to die very soon, communicate this clearly and sensitively to the person (if conscious and have not indicated they would not wish to know) as well as family and those important to the person. If the person has mental capacity, discuss their wishes at the time.
Take into account the person’s views and choices. Develop and document a plan of care.
Regularly review the person to make sure the plan of care is still appropriate and respond to changes in condition, needs and choices.

2. Communicate

Remember that open, honest and sensitive communication is key.
Use clear, concise and plain language – in speaking and in all other forms of communication.
If needed, provide support to help the dying person and their family understand information, communicate their wishes or make choices.
Remember that communication is two way. Listen to the views of the person and those important to them, not simply provide details. Any differences of opinion should be openly discussed.
Communication must be respectful in tone and pace. Think about what the dying person, and those that are important to them want and feel able to discuss at this time and in the future.
Check the other person’s knowledge of information that is being communicated, and detail this.

3. Involve

Involve the dying person, to the extent they wish to be, in day to day decisions about food, drink and personal care and in clinical and treatment choices.
Find out, and respect, the extent to which the person wishes their family and those important to them to be involved in decision making.
Tell the person, and those important to them, who is the senior doctor who has responsibility for their treatment and care, and who is the nurse leading their care.
Check whether there is an advance care plan in place.
Where it is known that the dying person lacks mental capacity to make a decision, action taken on their behalf must be in their best interests. Involve them as far as possible. Consult an independent mental capacity advocate (IMCA) if the person lacks capacity and has no family, friends or carer.

4. Support

Remember that families and those important to the dying person, as well as carers, have their own needs which can be overlooked at this time.
Recognise that they may be physically and emotionally tired, anxious or fearful.
Ask about their needs for support and meet these as far as possible.
Listen to their needs and wishes, even when it is not possible to meet all of them.
Where a dying person lacks capacity, explain the decision making process to those people who support them and involve them as much as possible.

5. Plan & do

Develop a personal plan of care and treatment to meet the dying person’s own needs and wishes. Document this so that consistent detail is shared with those involved in the person’s care and is available when needed.
Look at symptom control. Consider the 5 key symptoms of pain; breathlessness, agitation, respiratory secretions and nausea and vomiting.
Look at the person’s physical, emotional, psychological, social, spiritual, cultural and religious needs.
Support the person to eat and drink as long as they wish to do so and are able to do so safely.
Refer to specialist palliative care if needed and ring for advice if unsure about anything.

End of Life Care Practice Development Team

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