Policy Statement

This organisation seeks to ensure that advance care planning (ACP) is a service that meets and supports the needs of its service users, their families, and the wider community. Ours is an ageing society in which the dying phase is being extended and, in many cases, is being entered into imperceptibly. Key factors, such as family structures and different models of family life, mean that services at the end of life are often provided by social care providers. This policy clarifies how we will work in conjunction with multi-agency partners to ensure that we play our part when required to deliver quality, person-centred ACP.

The Policy

Key Principles of Advance Care Planning

The process is voluntary. No pressure should be brought to bear on the individual concerned to take part in ACP by the professional, the family, or any organisation.

ACP must be a person-centred dialogue over a period of time.

The process of ACP reflects 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 that may be instigated by an individual and know how to respond to their questions.

Health and social care staff should instigate ACP only when their professional judgement 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 the 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 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, e.g. chemotherapy or intravenous therapy. Individuals may need to be admitted to the 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 on what is then planned. The 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 to the requirements of the Mental Capacity Act 2005 (MCA).

Advance Care Planning

ACP is a voluntary process of discussion about future care between an individual and their care providers. If the individual wishes, their family and friends may be included. It is recommended that, with the individual’s agreement, this discussion is documented, regularly reviewed, and communicated to key persons involved in their care. An ACP discussion includes:

The individual’s concerns and wishes.

Their important values or personal goals for care.

Their understanding of their illness and prognosis.

Their preferences and wishes for types of care or treatment that may be beneficial in the future, as well as their availability.

If the individual wishes, ACP may be an integral part of the care and communication process and their regular care plan review. The difference between ACP and care planning more generally is that the process of ACP will usually take place in the context of an anticipated deterioration in the individual’s condition in the future, with attendant loss of capacity to make decisions and/or ability to communicate wishes to others.

A record of ACP discussions is documented in the care plan. Interviews and recording of discussions are achieved by using an open question style of dialogue.

For individuals with capacity, it is their current wishes about their care that need to be considered. Under the MCA, individuals can continue to anticipate future decision making about their care or treatment should they lack capacity. In this context, the outcome of ACP may be the completion of a statement of wishes and preferences or, if referring to the refusal of specific treatment, may lead to an advance decision to refuse treatment (Chapter 9: MCA 2005 Code of Practice). This is not mandatory or automatic and will depend on the person’s wishes. Alternatively, an individual may decide to appoint a person to represent them by choosing a person (an ‘attorney’) to take decisions on their behalf, if they subsequently lose capacity (Chapter 5: MCA 2005 Code of Practice). A statement of wishes and preferences is not legally binding. However, it does have legal standing and must be taken into account when making a judgement in a person’s best interests. Careful account needs to be taken of the relevance of statements of wishes and preferences when making best interest decisions (Chapter 5: MCA 2005 Code of Practice).

If an advance decision to refuse treatment has been made, it is a legally binding document, if that advance decision can be shown to be valid and applicable to the current circumstances.

If it relates to life-sustaining treatment, it must be a written document that is signed and witnessed. In all cases, an individual’s contemporaneous capacity must be assessed on a decision-by-decision basis. An individual may retain the ability to make simple decisions but not more complex decisions (Chapter 4: MCA 2005 Code of Practice).

ACP may be instigated by either the individual or a care provider at any time, not necessarily in the context of illness progression, but maybe at one of the following key points in the individual’s life:

Life changing event, e.g. the death of a spouse, close friend, or relative.

Following a new diagnosis of a life-limiting condition, e.g. cancer or motor neurone disease.

A significant shift in treatment focus, e.g. chronic renal failure where options for treatment require review.

Assessment of the individual’s needs.

Multiple hospital admissions.

Sometimes people will want to write down or tell others their wishes and preferences for future treatment and care or explain their feelings or values that govern how they make decisions. Statements of wishes and preferences or documented conversations the person has had with their family or other carers may be recorded in the person’s notes. A statement of wishes and preferences can be of various types, for example:

A requesting statement reflecting an individual’s aspirations and preferences. To help health and social care professionals identify how the person would like to be treated, without binding them to that course of action, if it conflicts with professional judgment.

A statement of the general beliefs and aspects of life that an individual value. This might provide a biographical portrait of the individual that subsequently aids in deciding their best interests.

Statements of wishes and preferences can include personal preferences, such as where one would wish to live, having a shower rather than a bath, or wanting to sleep with the light on. Sometimes people may wish to express their values, e.g. that the welfare of their spouse or children is taken into account when decisions are made about their place of care. Sometimes people may have views about treatments they do not wish to receive, but do not want to formalise these views as a specific advance decision to refuse treatment. These views should be considered when acting in a person’s best interests, but will not be legally binding. A statement of wishes and preferences cannot be made in relation to any act which is illegal, e.g. assisted suicide.

Best Interest Decision

Under the MCA, anybody deciding on the care or treatment of an individual, who has been assessed as lacking the capacity to make that decision for himself, will be required to take any statement of wishes and preferences into account when assessing that person’s best interests. Part of assessing best interests should include making reasonable efforts to find out what a person’s wishes, preferences, values and beliefs might be. This is likely to involve contacting the person’s family or other care providers. They may be able to advise whether any statements of wishes or preferences exists or to help in determining that person’s wishes. This will not always be possible, e.g. if an individual is admitted as an emergency, is unconscious, and requires rapid treatment.

A person assessing an individual’s best interests must:

Not make any judgement using the professional’s view of the individual’s quality of life.

Consider all relevant circumstances and options without discrimination.

Not be motivated by a desire to bring about an individual’s death.

Consult with a family, partner, or representative as to whether the individual previously had expressed any opinions or wishes about their future care, e.g. ACP.

Consult with the clinical team caring for the individual.

Consider any beliefs or values likely to influence the individual if they had capacity.

Consider any other factors the individual would consider if they were able to do so.

Consider the individual’s feelings.

Advance Decision

During ACP discussions, it may become apparent that the person wishes to make an advance decision to refuse treatment. The making of an advance decision should be made under the guidance of someone who understands the complexities of the process. The professional involved in the discussion should be willing and able to discuss what is involved in the making of an advance decision or be able to give direction as to the appropriate action to be taken (refer to the MCA Code of Practice, Chapter 9).

The MCA provides the statutory framework to enable adults with the capacity to document clear instructions about the refusal of specific medical procedures should they lack capacity in the future.

An advance decision to refuse treatment:

Can be made by someone over the age of 18 who has mental capacity.

Is a decision relating to the refusal of specific treatment and maybe in specific circumstances.

Can be written or verbal.

If an advance decision includes refusal of life-sustaining treatment, it must be in writing, signed, and witnessed, and include the statement ‘even if life is at risk’.

Will only come into effect if the individual loses capacity.

Only comes into effect if the treatment and circumstances are those specifically identified in the advance decision.

Is legally binding, if valid and applicable to the circumstances.

Part of ACP is recording any lasting power of attorney (LPA). Under the MCA, the holder or holders of a personal welfare LPA may be appointed by the individual to make all or specific health and welfare decisions on their behalf, should they lose capacity, as if they were the person receiving care. In particular, the individual must specify whether the appointed holder of the LPA has the authority to make decisions on life-sustaining treatment. Any decisions taken by the appointed person must be made in the individual’s best interests. Part 1, Section 4, of the MCA gives a checklist to define best interests.

This organisation recognises that ACP does not stop at the point of death. Often for the carer and family further support is needed, especially in the wake of a death. Discussions must take place with the carer and the family, so that agreement can be reached about the level and need of support required. This will inevitably vary according to the family’s structure and inter-dependency. A carer’s support plan should detail these requirements and this can include emotional and practical bereavement support.

My Covid-19 Advance Care plan

The NHS have published guidance and a template for this Advance Care Plan.

It is a page of information which is written by the individual with friends and family or someone of their choice. It is a place to write down quickly and in one place, the thoughts and wishes the individual has on the care and support they would like if they developed severe COVID-19 symptoms. We will inform and support our service users if they wish to complete this additional advance care plan.

Related Policies


Co-operating with other Providers

Deprivation of Liberty in Community Settings


Equality and Diversity

Meeting Needs

Mental Capacity Act 2005

Related Guidance

NICE Advance Care Planning a quick guide:

My future wishes: Advance care planning (ACP) for people with dementia in care settings:

RCN Royal College of Nursing:

Missed Opportunities:

NICE Guideline 108: Decision-making and mental capacity:

Training Statement

All staff, during induction, are made aware of the organisation’s policies and procedures, all of which are used for training updates. All policies and procedures are reviewed and amended where necessary, and staff are made aware of any changes. Observations are undertaken to check skills and competencies. Various methods of training are used, including one to one, online, workbook, group meetings, and individual supervisions. External courses are sourced as required. [AMEND AND INSERT AS REQUIRED]


Date Reviewed: October 2022

Person responsible for updating this policy:

Next Review Date: October 2023

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