Meaningful conversations with an individual, their families and/or legal proxy about their goals and preferences, are central to person-centred high quality Anticipatory Care Planning (ACP).
Good outcomes depend on professionals using sensitive and effective communication behaviours and clear language within a robust overall conversation framework. Wherever possible they should take place face-to-face. However the COVID-19 pandemic has shown that it is also possible to use video (NHS Near Me) or phone. This is more likely to be acceptable if an established relationship exists between the person and the health or care professional.
The 6-step RED-MAP framework offers a helpful model to guide health and care professionals having care planning conversations. RED-MAP includes optional prompts for each step. These should be adapted to the individual and their situation.
- Ready: Introduce ACP and outline why it helps people get better care
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 think about what might happen for (person’s name) and what will be of help to them."
- Expect: Find out what the person knows, and thinks might happen
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?"
- Diagnosis: Share health information tailored to the person
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…"
- "Do you have any thoughts, questions or worries I can help with?"
- Matters: Talk about what is important to the person and their family
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 they would say about this situation, if we could ask them?"
- Actions: Discuss realistic options for this person
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?"
- "Can I ask if you know anything about cardio pulmonary resuscitation or CPR?"
Where appropriate, Cardiopulmonary Resuscitation (CPR) should be discussed as part of a wider ACP conversation. Prior to the conversation make a clinical assessment of the outcome of CPR for this person. Discuss CPR outcomes in line with their clinical situation.
- "Can I ask if you know anything about cardio-pulmonary resuscitation or CPR?
- "Has anyone discussed it with you before?"
- "CPR is treatment to restart the heart and breathing.
- CPR does not work when a person is in very poor health or dying, so it is better for us to plan good care.
- With these health problems, CPR may work but can leave a person in much poorer health. Can we talk about your situation?"
- Any other treatments that can help will be given.
- Plan: Agree a plan that is right for this person
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."
There are a range of materials that you can access:
- Downloadable version of the RED-MAP framework.
- Video recording: Using RED-MAP - talking about planning care, death and dying using RED-MAP by Dr Kirsty Boyd. Produced by the Royal College of Physicians and Surgeons of Glasgow.
- NHS Education for Scotland has developed a range of training materials to support Realistic Medicine which aims to put the person at the centre of decisions made about their care.
- RED-MAP framework for ACP conversations used with permission from Dr Kirsty Boyd, Reader in Palliative Care, The University of Edinburgh.
- RED-MAP graphic developed by Openchange.