Advance Care Planning

Advance care planning (ACP) is a process of discussion between a person, their care providers, and those important to them. It enables the person to express their wishes, preferences, and priorities for their future care — including decisions about treatments they would or would not want.

Key Principles of Advance Care Planning

Person-centred:The person's wishes and preferences must be at the centre of all decisions
Voluntary: ACP is entirely voluntary — no one should be pressured into making decisions
Mental Capacity: The person must have the mental capacity to make advance decisions — if capacity is lost, previously recorded wishes must be respected (Mental Capacity Act 2005)
Reviewed regularly:An advance care plan should be reviewed whenever the person's condition or wishes change
Shared:The plan should be shared with all those involved in the person's care, including the GP and any specialists

DNACPR (Do Not Attempt Cardiopulmonary Resuscitation)

A DNACPR decision records that if a person's heart or breathing stops, CPR should not be attempted. This is a clinical decision made by a senior clinician, but it should be discussed with the person (if they have capacity) or their legal representative.

Key Points

A DNACPR decision applies only to CPR — it does not mean “do not treat” or withdrawal of any other care
The ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) form is now widely used and includes DNACPR decisions alongside broader emergency care recommendations
The decision must be recorded clearly, reviewed regularly, and communicated to all relevant staff
If a person with capacity refuses CPR, this must be respected under the Mental Capacity Act 2005

Lasting Power of Attorney (LPA)

A Lasting Power of Attorney is a legal document that allows someone to appoint one or more trusted people to make decisions on their behalf if they lose the capacity to make those decisions themselves. There are two types relevant to care planning:

Health and Welfare LPA

This allows the attorney to make decisions about the person's medical treatment, care, and daily routine. It can only be used when the person has lost capacity. This is the most relevant LPA for advance care planning.

Property and Financial Affairs LPA

This allows the attorney to make decisions about the person's finances and property. It can be used while the person still has capacity, with their permission.

Note: An LPA must be registered with the Office of the Public Guardian before it can be used. It must be set up while the person still has mental capacity. Care homes should check on admission whether a resident has an LPA in place and record the details of any attorney.

Advance Decision to Refuse Treatment (ADRT)

An Advance Decision (sometimes called a “living will”) is a legal document where a person states which treatments they would not want to receive in specific circumstances if they later lose capacity. Under the Mental Capacity Act 2005:

An ADRT is legally binding if it is valid and applicable to the situation
If a person wants to refuse life-sustaining treatment, the ADRT must be in writing, signed, witnessed, and include a statement that it applies even if their life is at risk
An ADRT can be withdrawn or changed at any time while the person still has capacity

Advance Care Plan Form

Use this form to record a resident's advance care plan. This should be completed in conversation with the resident (where possible), their family, and the care team. Print this page for a paper version.

Personal Details

Full Name

Date of Birth

NHS Number

Key Contact / Next of Kin

GP Name and Practice

Understanding My Condition

Current Diagnosis / Conditions

What I Understand About My Condition

What Matters Most to Me

My Wishes for Future Care

Where I Would Like to Be Cared For

What Treatments I Would Want

What Treatments I Would NOT Want

My Views on Cardiopulmonary Resuscitation (CPR)

My Views on Hospital Admission

My Views on Artificial Nutrition and Hydration

Any Other Wishes or Preferences

Legal Documents

Advance Decision to Refuse Treatment (ADRT) in Place?

Lasting Power of Attorney (Health & Welfare) in Place?

If Yes — Attorney Name and Contact

DNACPR / ReSPECT Form in Place?

DoLS Authorisation in Place?

Comfort and Quality of Life

What Gives Me Comfort and Joy

How I Like to Be Supported When Unwell

Spiritual or Religious Needs

Who I Want With Me When I Am Dying

My Funeral Wishes (if discussed)

Review

Date of Discussion

Discussed With (names and roles)

Date to Review This Plan

Signature of Person (or How Consent Was Gained)

Signature of Lead Professional

Official Resources

⚠️ Important Notice

The advance care planning guidance on Care Handbook is for informational purposes only and does not constitute medical, legal, or professional advice. Always follow your care home's policies and procedures, consult the resident's GP or palliative care team for clinical decisions, and seek legal advice for matters relating to advance decisions, lasting power of attorney, or DNACPR. The Mental Capacity Act 2005 and its Code of Practice must be followed at all times.