Advance Care Planning (ACP): Guidance for health and social care professionals

Community nurse with patient in his home

Caring for people at the end of their lives is an important role for many health and social care professionals. One of the aspects of this role is to discuss with individuals their preferences regarding the type of care they would wish to receive and where they wish to be cared for, in case they lose capacity or are unable to express a preference in the future.

These discussions clearly need to be handled with skill and sensitivity. The outcomes of such discussions may then need to be documented, regularly reviewed and communicated to other relevant people, subject to the individual’s agreement. This is the process of Advance Care Planning (ACP).

ACP in its simplest terms is ‘a process of discussion between an individual and their care providers irrespective of discipline’.

The difference between ACP and planning more generally is that the process of ACP is to make clear a person’s wishes and 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.

With the individual’s agreement, discussions should be:

  • documented
  • regularly reviewed
  • communicated to key persons involved in their care.

If the individual wishes, their family and friends may be included.

Examples of what an ACP discussion might include are:

  • The individual’s concerns
  • Their important values or personal goals for care
  • Their understanding about their illness and prognosis, as well as particular preferences for types of care or treatment that may be beneficial in the future and the availability of these.

Documentation of ACP

There is no set format for making a record of advance care planning discussions, although having a person’s wishes documented will prove helpful to those involved in their future care.

In Wigan Borough the ‘Preparing for your Future Care’ document is frequently used to help focus such conversations.

The Hospice in your Care Home team are happy to organise such discussions with residents in nursing homes or support the staff to facilitate this activity.

ACP and the Mental Capacity Act (MCA)

For individuals with capacity it is their current wishes about their care which needs to be considered. Under the MCA of 2005, 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 refusal of specific treatment may lead onto an advance decision to refuse treatment.

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 which is signed and witnessed.


For further information on Advance Care Planning please call us on 01942 525566 or email: