Anticipatory Care Planning

Frequently Asked Questions and Form

What is anticipatory care planning?

The ACP is a record of the preferred actions, interventions and responses that care providers should make following a clinical deterioration or a crisis in the person's care or support. This can be done on a voluntary basis by patients or can be a agreed plan based on a discussion with the Clinician responsible for your care, this can be your GP/practice nurse or a member of the district nursing team.

Anticipatory care planning is more commonly applied to support those living with a long term condition to plan for an expected change in health or social status.

• Everyone is different. It helps us make better decisions about treatment and care if we know what matters to you.

• Some people are keen to get better no matter what. They want us to look at any treatments that could prolong their life, even if that means Admission to hospital.

• Some people want to get better, if possible, but think that quality of life is important too. These people want us to think about Admission to hospital if there is a good chance of getting back to how they are normally. If hospital treatments may not help or could mean being in much poorer health, they would rather stay in their own home or care home and be looked after by community staff or the care home staff and their GP.

• Some people feel that staying in their home or care home to be looked after in a familiar place and not going to hospital is the right thing for them. They may not want the upset of going to hospital for treatments that might not work. Being comfortable at home or in the care home is more important.

Who should have an Anticipatory Care Plan?

This is a voluntary process and the decision to have one rests with the individual. Having an Anticipatory Care Plan would be particularly helpful for people who:

• Live in a care home
• Are being proactively care managed
• Have complex, palliative or end of life care needs.

Some Conditions where it may be particularly helpful include:

• Advanced long term condition e.g. COPD in receipt of domiciliary oxygen

• People receiving enhanced support from a specialist nurse

• People referred to or attending memory clinic

• People with dementia

• People with significant learning disability

• People with significant mental health problems

How does it apply if you have dementia?

Most people with early dementia retain the capacity to make informed choices and decisions, an anticipatory care plan should be initiated as soon as possible after diagnosis whilst the person can still be an active participant. This might be also a time to consider who should have power of attorney should the condition worsen and affect your ability to make decisions for yourself.

How we share Anticipatory Care Plans?

Anticipatory Care Plans is shared with the full range of care providers involved, including NHS 24 and Out of Hours Services, so that all are aware and can respond to the expressed wishes.

For further information on anticipatory care planning please visit: www.nhsinform.scot/care-support-and-rights/palliative-care/planning-for-the-future/make-an-anticipatory-care-plan.

If any of the above applies to you and If you wish to have a anticipatory care plan- please fill in the form: Anticipatory Care Form (DOCX, 20KB) and send it to the surgery - your responsible Clinician may contact you for further information.