Anticipatory Care Planning

Throughout this series of blogs, you will hear repeatedly that our population is ageing and that is really good news.  However, we are also aware that the likelihood of having long-term, multiple chronic or complex conditions increases with age.  So, as healthcare professionals need to have models of care that are designed to meet the many needs of individuals.

Anticipatory Care Planning (ACP) is part of that support. So, what is Anticipatory Care Planning?  It’s about ‘thinking ahead’ and planning action or taking action before something happens.

It involves having detailed collaborative conversations between the person, their family and their care team about future care and preferred options. The process can also be used to explore how individuals can participate in their own care as an extension of self-management.

Anticipatory care planning conversations can be uncomfortable to initiate however with practice it becomes easier and as your experience develops you will become more confident in your approach.  Some people may wish to start the conversation themselves which is great, however others may experience anxiety when considering their future and may wish to avoid having such discussions until they are ready.  This is when your coaching skills will be of great value.

There will be many opportunities to start the process during care interactions and these conversations should focus on the person’s health, well-being and their actual clinical conditions in an attempt to reduce possible crises.  ACP’s also identify where  the person wishes to be  cared for and though collaborative discussion,  it helps identify their own personal outcomes.

Anticipatory Care Planning conversations are completely voluntary and are in no way  legally binding. We know people often change their wishes as circumstances change, so it is vitally important that care preferences are recorded in an ACP with any changes highlighted, dated and communicated to the wider care team.   Example ACP’s can be found at  https://ihub.scot/project-toolkits/anticipatory-care-planning-toolkit/anticipatory-care-planning-toolkit/

Anticipatory Care Planning conversations should be:

  • Collaborative: Individuals and carers are at the centre of their ACP conversations
  • Ethical:  Respect for the person’s values, beliefs and preferences for care, by including what matters to them
  • Comprehensive: Clear communication of key information (e.g. individuals or care providers involved in care or support requirements)
  • Informative communication: Establishes a robust pathway of communication sharing (including e-sharing), which can be helpful to other colleagues, care providers or agencies involved in care. Improving individuals understanding of their health and well-being (health literacy) is essential to person-centred care models which incorporate effective communication, self-management and essentially patient safety
  • Self management approach:
    • Demonstrates the unique symptoms the person may experience and simple actions they can take to address them
    • Enables early identification of health change or health needs, and relevant interventions required to support recovery or reduce crisis
  • Personal:  Information that is important to the individual or carer
  • Relevant: Highly important matters e.g. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) status and  Power of Attorney
  • Realistic: Recovery goals that reflect the individual’s hopes, aspirations and preferences e.g. “Things that I must do to keep well” or “What is important to me and why?” Such measures may help to facilitate hope and encourage active participation in the ACP process.
  • Carer considerate: Enabling alternative arrangements or contingency plans in the event of the carer becoming unwell, thereby reducing the need for acute admission to hospital.

(Barrie, Steel & Loughlin 2019, in Essentials of Nursing Adults, Eds: Elcock, Wright, Newcombe & Everett, Sage, London)

Please take some time to watch some of the personal experiences of those who have undertaken developing an ACP before and hear how important this was to them. 

https://ihub.scot/project-toolkits/anticipatory-care-planning-toolkit/anticipatory-care-planning-toolkit/videos/

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