Advance care planning: Information for clinicians

Consider starting ACP conversations:

• New diagnoses of life-limiting conditions
• Following hospital admission or episode of critical illness
• When patients or families raise questions about future care
• Annual reviews for patients with frailty or multiple comorbidities

Begin with what matters most to the patient and build incrementally.

Useful prompts include:

• "What really matters to you? What does a good day look like? "
• "What are your biggest worries about becoming unwell?"
• "If you were unable to make decisions, what would be most important for us to know?"

A statement of wishes is a non-binding way of capturing this information that can inform best interest healthcare decisions in the future. It can be a typed or written note and can be uploaded to the electronic health care record. Patients should be encouraged to share it with those who matter to them.

Patients should seriously consider appointing attorneys for:

• Property and Financial Affairs
• Health and Welfare: for healthcare decisions when the patient lacks capacity

See more detailed information on lasting power of attorney here.

This is an important part of ACP discussions as it will be brought up at every hospital admission and is relevant if a patient wants to stay at home.

For guidance on discussing CPR and DNACPR decisions see Cardiopulmonary Resuscitation: Information for clinicians.

For North West London a Universal Care Plan (UCP) should be created which records the resuscitation decision. Paramedics access this when called out in an emergency.

Record formal ACP discussions in:

• GP clinical system with prominent alerts
• Hospital discharge summaries
• The Universal Care Plan (UCP)

A statement of wishes can also be uploaded to the GP clinical system.