Beginning the Process

It is important for the individual (and the health and care professional) to understand that it is the person's Anticipatory Care Plan and they should have ownership of it.

Before developing an Anticipatory Care Plan supported by a health and care professional, it is important that the person understands its relevance so that the conversation can be placed in context. Individuals should be helped to understand that ACP is a voluntary process. The ACP documents belong to the individual and are not considered to be "legal" documents. Initial discussion should involve exploring their understanding of their conditions and prognosis.

All conversations should involve simple and clear language, with technical terminology avoided as much as possible. The person should be reassured that ACP is an opportunity to clarify their priorities and wishes for their future care and to plan accordingly. ACP encourages them to focus on what is important to them, to talk about the future if they wish (including death and dying) and to feel more in control of their future care.

The following points may help with this process:

  1. ask the person what they understand about their current situation and what they think might happen in the future. It is useful to know what they have been told by other health and care professionals and have learnt from other sources, like the Internet.
  2. ask about past experiences with illness, either their own or others.
  3. clarify concerns, expectations and fears about the future in relation to their health care.
  4. identify any gaps in their understanding by describing what ACP is and what the rationale is for having ACP conversations. They should be made aware that they are able to change their views and preferences at any time and make changes to their Anticipatory Care Plan as and when they wish.

People may need time for reflection and discussion after they have had an initial discussion about ACP.

ACP conversations should take place in an environment that:

  1. is non-threatening
  2. offers privacy, quietness, space and time for reflection, and
  3. is familiar to the person so that they feel comfortable.

Some people may wish to be accompanied or supported by someone close to them and others may prefer these discussions to take place privately. It is important to check this with the person.

Key Information Summary

The Key Information Summary (KIS), currently hosted on the GP IT system, enables the development of an electronic Anticipatory Care Plan from the GP system. It can also be accessed across other services in acute and emergency care. The KIS contains information considered valuable to informing appropriate interventions. Ongoing work is focused on evolution of KIS to enable greater accessibility and cross-sector working.

If an Anticipatory Care Plan is developed, a KIS can be completed in the GP electronic record and contain ACP information and wishes. This can be shared with other healthcare settings with the person’s consent.

Clinical Management Plan

It might be appropriate for the professional supporting the individual to summarise important clinical details in the clinical management plan at the end of the Anticipatory Care Plan.