Workshop 3 ‘End of Life Care’: NPT Master Class Implementation Scenario Example implementation scenario: Advanced Care Planning (ACP) What is the intervention?

Advance care planning (ACP) provides patients with an opportunity to think about and plan their wishes and preferences about their care, should they become incapable of participating in and making decisions about their medical treatment. These discussions can result in an advanced directive care document or can involve ongoing discussions about end of life care.

What does the intervention consist of?

Advance Care Planning (ACP) consists of discussions between health professionals and individuals who have capacity about their individual preferences, wishes, beliefs, values and feelings. It is recommended that with the individual’s agreement that discussions are documented, regularly reviewed, and communicated to key persons involved in their care.

How is this different from what staff ‘normally’ do (previously ‘did’)?

The difference between advance care planning and general care planning is that the process of ACP can only involve someone with capacity to decide and usually takes 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 the ability to communicate wishes to others. The process is voluntary and a written record of a patient’s wishes and preferences may be referred to by carers and health professionals in the future. If a patient loses capacity, health and social care professionals and family members can make use of information available in advanced care plans to guide them in decision making when it is needed.

What are the different staff/individuals involved in delivering the intervention?

The key groups involved in Advance Care Planning (ACP) are GP’s, specialists; community nurses; patients; family members; carers and care home staff.

What staff/individuals are most involved in delivery of the intervention?

The staff/individuals that are mostly involved in the delivery of Advance Care Planning (ACP) are GP’s, community nurses; patients; family members; carers and care home staff.

What might make the implementation of this particularly complex?

The implementation of Advance Care Planning (ACP) is complex due to a number of factors, such as, disagreements between individuals and groups about ‘best interests’ to patients; understanding the scope and responsibility of roles; distinguishing between ‘care planning’ and ‘advance care planning’, and areas of overlap.

Associated publication: Sampson et al. Palliative care in advanced dementia; A mixed methods approach for the

development of a complex intervention. BMC Palliative Care 2008, 7:8