Make an anticipatory care plan

Anticipatory care planning (ACP) helps you make informed choices about how and where you want to be treated and supported in the future. It requires health and care practitioners to work with people and their carers to ensure the right thing is done at the right time by the right person to achieve the best outcome.

ACP puts people at the centre of the decision-making process about their health and care needs. By encouraging people to have conversations about what matters to them ACP can help:

  • manage change in an organised way
  • prevent crisis
  • reduce future stress
  • promote quality of life

Eligibility

ACP is about thinking ahead and being in control of any changes in your health conditions. Anyone at any age may benefit from having a plan.

People with more complex needs are likely to benefit most from ACP as it will ensure their support is:

  • coordinated
  • tailored to their needs
  • informed by their choices and situation

ACP may also help:

  • people who're elderly, housebound or living alone
  • people with mental health or social support needs
  • infants, children and young people with palliative care needs
  • families and carers under stress

When to start the planning process

A plan can be started at any stage of a person’s care and is often suggested by their healthcare team. This could be after life events such as a hospital admission or decline in health.

If you've been diagnosed with an illness that's likely to get worse, your healthcare team may think it helpful to make a plan for you. If so, they'll work with you to do this. If you aren't asked about making a plan but feel this is important to you, you can tell your healthcare team about your desire to make one.

What to include in your plan

An anticipatory care plan is a record that should be developed over time through conversations, shared working and decision-making between you and your healthcare team.

It's a good idea to think about what you want or don’t want to happen in the future regarding any care you might need. In order for this to work, you might want to think about talking to:

  • your friends and family
  • any health or social care professionals you see regularly (for example your doctor or nurse)
  • a lawyer

Your plan is a document that can be used to record the details of these discussions. 

The plan should include:

  • a summary of the “thinking ahead” discussions between you, those close to you and the health and care professionals supporting you
  • a record of your goals, preferences, views and concerns
  • a record of your preferred actions, treatments and responses that care providers should make following a decline in your health or a crisis in your care or support
  • reviewed and updated information as your condition or needs change and different things take priority
  • current plans in place such as Power of Attorney, Welfare Guardianship and wills or the need to set these up
  • your wishes and views about end of life care, including your preferred place of care, as well as your views about whether or not cardiopulmonary resuscitation is appropriate or wanted

With your consent, your plan should be shared with all those involved in your care.

ACP Matters 2017 (https://www.youtube.com/watch?v=UkIQTUpbwbU)

Watch the ACP Matters 2017 video to find out how anticipatory care planning is changing lives across Scotland.