ACP involves conversations between individuals, their families, carers, and professionals. It helps people communicate goals and preferences, and gives them opportunities to consider realistic options and plan for future changes in their health and care that can be recorded, shared and reviewed.
ACP is a person-centred, proactive approach to help people consider what is important to them and plan for their future care. Planning ahead can help people feel more in control and able to manage any changes in their health and wellbeing. People should be offered opportunities to take part in care planning and receive information about its benefits.
Understandably, they may have worries and concerns that need explored. Sometimes people will not wish to engage in these discussions, or may prefer to delay them until another time when they are ready.
Thinking ahead about ‘what matters to me’ is relevant at any age or stage of life. Undertaking ACP is particularly beneficial for those:
- living with one or multiple long term health conditions
- living with disabilities and/or complex health and care needs
- whose health and wellbeing is changing or deteriorating due to physical and/or mental health problems
- approaching the end of their life, and
- children and young people with life-limiting conditions.
Central to ACP are conversations between individuals, those people who are important to them (for example: a relative, close friend or carer, or a legal proxy), and their health or social care professionals. These conversations inform shared decisions about future care and can include:
- reflections on an individual’s situation, goals, priorities and preferences in relation to their health and care
- involving the right people and supporting them to be part of discussions and decisions about future treatment and care, and
- discussing and agreeing realistic treatment or care options in line with what matters to them.
These discussions and decisions are recorded in an anticipatory care plan and shared with the people that need to know about it. Care plans must be reviewed if the individual’s health condition or social situation changes, or as they wish to do so.