These prompts may help you open a conversation with the person and those close to them:

• "Can we talk about what is happening with your health in case you (or people who support and help you at home) get less well in future?"
• "It is helpful to think ahead and talk about what might happen so we know what is important for you."
• "Have you talked about planning ahead for your treatment and care before?"
• "Do you have any kind of plan already? Is there someone who has power of attorney for you?"
• "We can talk about what might happen for (person’s name) and what will be of most help to them."

Once the conversation has started, we explore understanding and concerns:

• "Can I ask what you know about your health problems?"
• "How have you been doing recently, and has anything changed?"
• "Have you thought about what might happen if you get less well or seriously ill?"
• "Do you want to tell/ask me anything important for you or your family?"

It is important for people to have information about their health conditions or diagnoses so they can think about what is important to them before making plans for the future. Acknowledge and share uncertainty.

• "What we know is that…"
• "We don’t know exactly what will happen or when, but we can plan for how to manage your treatment and care."
• "We are not sure about…"
• "I hope you will stay well/improve with..., but I am worried about…"
• "You may have thoughts, questions or worries we can talk about..."

This step is essential and explores what is important to the person:

• "Can we talk about how you would like to be cared for?"
• "What would you like to be able to do?"
• "Is there anything you do not want to happen or wish to avoid?"
• "What do you think (person's name) would say about this situation, if we could ask them?"

These depend on the person’s goals and preferences, place of care and clinical outcomes for them.

• "What we can do is..."
• "Options that can help you are…"
• "This will not help because..."
• "That does not work for someone when…"
• "I wish we could do that, can we talk about what is possible?"
• "Can we talk about what going to hospital might mean for you?"

Cardiopulmonary Resuscitation (CPR) is discussed as part of a wider ACP conversation, where appropriate. Make a clinical assessment of CPR outcomes. Discuss CPR in line with the person's clinical situation. You can learn more on the NHS Inform webpages on CPR.

• "Can I ask if you know anything about cardiopulmonary resuscitation or CPR?
• "Has anyone discussed it with you before?"
• "CPR is treatment to restart the heart and breathing after they have stopped."
  • "CPR does not work when a person is in very poor health or dying, so it is better for us to plan good care."
  • "CPR may work, but can leave a person in poorer health if they have certain underlying conditions."
  • "Some people choose not to have CPR."
• "Any other treatments that can help will be given. Can we talk about your situation?"
• "We use a DNACPR record to share information about CPR decisions."

Summarise the discussion, agree an anticipatory care plan, address current problems, and check for any questions or concerns.

• "We can plan ahead for if/when…"
• "We can make a personal plan for you called an ACP and share it securely with other professionals and teams so everyone knows what to do."
• "Any anticipatory care plans we make are reviewed if your health or situation change, and you can ask for a review at any time."