Adavance Care Plan

Writing Your Advance Care Plan


Advance care plans are a set of directions and future decisions about future care. They are often written when healthy and only take effect when we lose capacity of our body or mind. An 'Advance Care Plan' can help ensure that you are not given treatment that you do not wish to receive and that your family have power to act on your behalf if you wish them to.



Key principles of Advance Care Planning Process (by the National Council For Palliative Care)


The process of creating an Advance Care Plan is voluntary. No pressure should be brought to bear by the professional, the family or any organisation on the individual concerned to take part in writing an Advance Care Plan (ACP)


  • ACP must be a patient centred dialogue over a period of time
  • The process of ACP is a reflection of society’s desire to respect personal autonomy. The content of any discussion should be determined by the individual concerned. The individual may not wish to confront future issues; this should be respected
  • All health and social care staff should be open to any discussion which may be instigated by an individual and know how to respond to their questions
  • Health and social care staff should instigate ACP only if in the context of a professional judgement that leads them to believe it is likely to benefit the care of the individual. The discussion should be introduced sensitively 
  • Staff will require the appropriate training to enable them to communicate effectively and to understand the legal and ethical issues involved
  • Staff need to be aware when they have reached the limits of their knowledge and competence and know when and from whom to seek advice
  • Discussion should focus on the views of the individual, although they may wish to invite their carer or another close family member or friend to participate.
  • Some families may have discussed their issues and would welcome an approach to share this discussion
  • Confidentiality should be respected in line with current good practice and professional guidance
  • Health and social care staff should be aware of and give a realistic account of the support, services and choices available in the particular circumstances. This should entail referral to an appropriate colleague or agency when necessary
  • The professional must have adequate knowledge of the benefits, harms and risks associated with treatment to enable the individual to make an informed decision
  • Choice in terms of place of care will influence treatment options, as certain treatments may not be available at home or in a care home, e.g. chemotherapy or intravenous therapy. Individuals may need to be admitted to hospital for symptom management, or may need to be admitted to a hospice or hospital, because support is not available at home
  • ACP requires that the individual has the capacity to understand, discuss options available and agree to what is then planned. Agreement should be documented 
  • Should an individual wish to make a decision to refuse treatment (advance decision) they should be guided by a professional with appropriate knowledge and this should be documented according to the requirements of the MCA 2005.


"Many people find that working through an advance care plan is a good way to think about what would be important to them if their health was to change in a way which was well considered rather than rushed. In this way it can allow you to think about more of the aspects of what makes you you, and what is important to you, than you’re sometimes able to do if your health deteriorates quickly and have to make decisions quickly." - Palliative Care In Wales (source


Once you have written your Advance Care Plan it is important that you save it in a secure and safe place


Further resources


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