Advanced care planning

My Future wishes – A Guide to Advance Care Planning

This is a very useful resource pack about Advance Care Planning produced by West Yorkshire and Harrogate Health and Care Partnership. It provides lots of information about what advance care planning is, why it is important and guidance on how to carry it out. There are also embedded links to other guidance and tools.

Access My Future Wishes - A Guide to Advance Care Planning

Advance care planning – guidance for telephone or video conversations

Compassion in Dying has publisheda resource to support GPs with advance care planning conversations  over the phone or video, in the context of coronavirus.

What Matters to Me EPaCCS update – 24 April 2020

A new section has been added to the EPaCCs template “what matters to me”  This is to help personalised care planning with a patient and to help direct any future conversations with a health care professional. What matters to me can be printed off and given to the patient prior to advance care planning conversations.

Advance care planning – recommendations on preparing letters – 9 April 2020

Our recommendations are as follows:

1. We do not recommend an approach that involves writing letters to people raising Advanced Care Planning topics such as DNACPR
2. If in your clinical judgement an advanced care planning discussion would be appropriate, this needs to be a 1:1 conversation with the person, taking a compassionate, individualised, person-centred approach
3. It is important to involve families where appropriate and take care to ensure relatives know they are helping you make a decision in the best interests of the patient not having to make that decision themselves
4. We agree that it is particularly important that certain groups have the opportunity to have such conversations if possible. We would see the priority groups as being people living with severe frailty in care homes and their own homes
5. Community Paediatricians will review their caseloads for shielded patients and those patients at risk and where appropriate, and needed (i.e. if a plan is not already in place), they will have the conversation and ensure a plan is in place
6. LYPFT clinicians will have these conversations with patients in in-patient settings such as The Mount where this is appropriate

We note that much of this work is routine and that the Covid-19 outbreak has highlighted the need to ensure that everyone who deserves such a conversation is given the opportunity to do so.

Resources

• A COVID-19 support line for people who are bereaved or have a family member who is critically ill
• Please see for information the joint ethical charter from the RNC, RCGP and the hospice movement COVID EOLC Community Charter
• See this slide set from NHS Scotland that might be helpful to those leading ACP conversations.
• Please also see a useful one-page script for people having difficult discussions on the phone from Chelsea and Westminster FT.
• There is also a range of useful resources for professionals on the Leeds CCG website.

ReSPECT – 3 April 2020

Advance care plans for our patients living with frailty are vital during this pandemic.  To support Advance Care Planning in primary care an electronic form of ReSPECT has been generated and added to the EPaCCs template on the ReSPECT/DNACPR page.

Following a conversation with a patient or with their close family if they lack capacity a ReSPECT form can be generated and printed off and left in the patient’s home – enabling paramedics to see the patient’s expressed wishes.  Please note the electronic form cannot be seen in LTHT; they will only be able to view the paper form left with the patient.

Advance Care Plans should always be discussed with the patient if they have capacity.  If they lack capacity to engage with the process then it is reasonable to produce such a plan following best interest guidelines with involvement of family members or other appropriate individuals.

The Emis template was sent directly to each practice on the 10 April or can be accessed from the Emis Repository.  A short video has been produced to explain the ReSPECT process and how to use the template.  Please note this video was made before the COVID19 pandemic, the process has been rolled out straight away and has been attached to the old EPaCCs template.

Watch the video

TARGET presentation about the ReSPECT process

ReSPECT GP process map – COVID response:

To document how the processes will look in the future, on implementation of the new ReSPECT form.

Guidance for creating a ReSPECT form is below:

The LPCN are creating three short training videos to support ACP and management  of EOL COVID patients to support us in this area.