Discuss within your multidisciplinary team who should be prioritised for an ACP conversation. Consider people falling into any of the following three groups.

1. Situational factors:

• frequent unscheduled contacts including unplanned hospital admissions
• unable to leave home due to ill health
• carer or family stress
• following a move into a care home or on accessing respite care
• when a person has been identified as a vulnerable adult
• requiring specialist nurse or multidisciplinary team input, and
• when approaching the end of life.

2. Health conditions:

• complex physical or mental health needs
• diagnosis of frailty
• unstable or deteriorating long term health condition
• on certain disease registers, for example: palliative care, dementia, mental health or learning disability, and
• babies, children and young adults living with complex or palliative care needs.

3. Following assessment:

• requiring a polypharmacy review
• after a falls assessment
• identified as vulnerable or with unstable health needs
• following admission or discharge from hospital
• at chronic disease management annual reviews, and
• on the practice palliative care register.

Use of Tools to support identification

The Palliative Care Identification Tools Comparator provides detail of some of the tools that you can use to support the identification of those who would benefit from an anticipatory care plan. For example it includes the Supportive and Palliative Care Indicators Tool (SPICT) which identifies people with deteriorating health due to one or more advanced conditions or a new serious illness so they benefit from holistic assessment and future care planning.

ACP conversations can be challenging but are rewarding when based on building relationships with people and improving their care.

• Consider what time and resource will be required to undertake these conversations. Discuss this within your service, team, practice or health and social care partnership to explore how this is best provided.
• Agree who will lead on conversations with a person. If possible, this is a professional who knows the person. It could be a member of the primary care team such as the community nurse or a GP. Alternatively it could be a hospital or community-based specialist. For people living in a care home, the care home staff will usually know the person and their family.
• Ensure whoever leads the conversation has relevant training. There are a range of courses and resources that support staff in all care settings in Scotland to take part in ACP conversations.
• ACP conversations should never be rushed. It is important to give the person time to talk and ask questions. You may need to book a longer appointment to give you time to do this, or schedule a follow-up appointment so you can cover everything the person would like to discuss.

Help the person start to think about ACP and encourage them to talk with those close to them. Some useful conversation prompts include:

• “Can I arrange a time to talk with you about planning for future changes in your health and care?”
• “We would like to know what is important to you, and talk about what we can do to help you.”
• “Would you like anyone close to you to be involved?”

Offer public information for example websites, posters and leaflets. A range of materials are available:

• NHS Inform has a range of pages on ACP including general information on decisions about care.
• Good life, good death, good grief brings together a range of people and organisations interested in improving peoples experiences of death, dying and bereavement in Scotland. Their webpages include information on ACP.
• The Essential ACP Online Tool includes a Patient Information leaflet which talks about ACP in very general terms and may be useful in a range of contexts.

It is important to take a person-centred approach and to observe and follow the cues of the person you are working with. It is often helpful to involve relatives and carers in these conversations. This should always be done with the individual's consent.

Where the individual has impaired capacity and/or where there are speech, language, learning or communication support needs, health and care professionals leading the conversation should carefully consider their approach. The following may be helpful:

• Where someone has cognitive impairment or lacks capacity, identify and speak with their legal proxy.
• If you are working with someone who has a diagnosis of dementia there is specific guidance.
• It may also be worth seeking support from your local dementia post diagnostic support service who can work with a person over an extended period and support the development of an ACP as part of post diagnostic support. The ihub’s Focus on Dementia team has more information on this.
• Check if any aids have been identified to support communication with the person. If necessary speak to members of the multidisciplinary team, for example your local speech and language therapy department, who can provide advice and guidance on how to support communication needs.
• Use all available tools that support communication, for example the use of written prompts, communication aids and interpreter services.