What is an Advance Care Plan

Advance care plans are a set of directions and preferences concerning someone’s future care. They are often documented whilst someone is healthy and only take effect if they lose capacity of their body or mind.


Why you need an an Advance Care Plan

An ‘Advance Care Plan’ can help ensure that you are not given treatment that you do not wish to receive. It can also ensure that you receive the type of care you would like to receive in your preferred setting. An Advance Care Plan can also empower a friend or family member to make decisions and act on your behalf if you wish them to.

You can state your wishes in a paper Advance Care Plan. These can be obtained from your doctor, hospital and hospice. Alternatively you can use our free Advance Care Plan tool to document you wishes. Once completed simply download the document (as a PDF), print it or email it to someone you trust.

Key principles of Advance Care Planning Process

The process of creating an Advance Care Plan is voluntary. No pressure should be brought to bear by the professional, the family or any organisation on the individual concerned to take part in writing an Advance Care Plan (ACP)

  • An ACP must be a patient centred dialogue over a period of time
  • The process of ACP is a reflection of society’s desire to respect personal autonomy. The content of any discussion should be determined by the individual concerned. The individual may not wish to confront future issues; this should be respected
  • All health and social care staff should be open to any discussion which may be instigated by an individual and know how to respond to their questions
  • Health and social care staff should instigate ACP only if in the context of a professional judgement that leads them to believe it is likely to benefit the care of the individual. The discussion should be introduced sensitively
  • Staff will require the appropriate training to enable them to communicate effectively and to understand the legal and ethical issues involved
  • Staff need to be aware when they have reached the limits of their knowledge and competence and know when and from whom to seek advice
  • Discussion should focus on the views of the individual, although they may wish to invite their carer or another close family member or friend to participate.
  • Some families may have discussed their issues and would welcome an approach to share this discussion
  • Confidentiality should be respected in line with current good practice and professional guidance
  • Health and social care staff should be aware of and give a realistic account of the support, services and choices available in the particular circumstances. This should entail referral to an appropriate colleague or agency when necessary
  • The professional must have adequate knowledge of the benefits, harms and risks associated with treatment to enable the individual to make an informed decision
  • Choice in terms of place of care will influence treatment options, as certain treatments may not be available at home or in a care home, e.g. chemotherapy or intravenous therapy. Individuals may need to be admitted to hospital for symptom management, or may need to be admitted to a hospice or hospital, because support is not available at home
  • ACP requires that the individual has the capacity to understand, discuss options available and agree to what is then planned. Agreement should be documented
  • Should an individual wish to make a decision to refuse treatment (advance decision) they should be guided by a professional with appropriate knowledge and this should be documented according to the requirements of the MCA 2005.

(The Key Principles copy was provided by Dying Matters)

Advance care planning PDF

How to document your future care wishes on MyWishes.

Once you have created a MyWishes account our step by step video will visualise and describe how to create, download and share your advance care plan. Our support team will also be on hand to help support you should you experience any technical issues.

The animation below quickly highlights how our users create, download and share their Advance Care Plans.

Once you have completed your advance care plan you may also want to make plans for your online accounts in a social media wil or set yourself achievable goals within a bucket list. To learn more about all of MyWishes features click here.

stay at home

MyWishes free to use software was developed under the guidance of healthcare, hospice, legal and funeral professionals. To learn more about how MyWishes works click here.