Learning objectives

At the end of Unit 5, you will:

  • Understand how an advance care plan is recorded.
  • Understand how an advance care plan is shared.
  • Understand the importance of keeping an advance care plan up to date.

How are advance care plans recorded?

Reflective activity

  • Take a few minutes to think about how, and where, advance care plans are currently recorded and shared in your work setting.
  • How easy is it to locate an individual’s advance care plan? If you are unsure, who could you ask?

What to record?

  • It is important to record any decisions, wishes or preferences the individual and those important to them make regarding future care. This includes information about any of the items covered in Unit 3, for example the Statement of wishes and preferences for future care; Do Not Attempt Cardiopulmonary Resuscitation (DNACPR). These preferences may have been expressed during informal conversations with the individual or those important to them or during a planned advance care planning meeting.
  • It is also important to record any worries or concerns the individual or those important to them have, or any areas where decisions are not final. These will need to be reconsidered and discussed again.

How to record?

Advance care planning decisions, preferences and wishes should always be recorded within professional guidance and standards and local policies and procedures.

Detail:

  • Be thorough and detailed when recording an advance care plan.
  • Ensure that the information is clear and unambiguous.
  • Some decisions may need to be legally recorded through an Advance Decision to Refuse Treatment (ADRT), an advance directive (Scotland) and/or power of attorney.

Document:

  • The dates of conversations
  • Who they were with and by what means (‘face to face, digitally phone or email’)

* There will be policies and procedures in your work setting about how to record this information. These will differ across United Kingdom and health trust, but it is important you are aware of the process relevant to your area.

Where to record?

It is important to note that there is currently no standardised process for recording or sharing advance care plans across the UK. The recording and storing of an advance care plan will be different in different settings dependent on an organisation’s care record system. If you are unsure of the process for recording and sharing advance care plans, we recommend that you speak to a colleague with experience in the advance care planning process.

Advance care plans should be:

  • recorded on both paper and an electronic system to ensure they are easily accessible to a range of multi-disciplinary health and social care professionals.
  • Stored safely and securely with a note on the individual’s folder to say the advance care plan is in place.

Making it visible at the front of the patient’s file or notes will also make it more accessible in case of an emergency. You may wish to consider having several paper copies and provide the individual and those important to them with copies of the advance care plan in case multiple professionals need urgent access.

In Scotland and Northern Ireland, the Key Information Summary is the national electronic system where an advance care plan should be recorded. In England, the Summary Care Record is the national electronic system and in Wales this is the Individual Health Record.

Want to learn more? For further information on the topics discussed in this unit and documents used to record plans see the resource section.

Sharing advance care plans

An advance care plan should follow an individual throughout their care journey. Sharing advance care plans with necessary health and social care professionals, will increase the likelihood of the individual’s preferences and wishes being known and carried out.

Verbal Consent: It is important to ask the individual before sharing their advance care plan. However, it may be necessary to share advance care plans without consent, if this is in the best interests of the individual.

The policy for sharing advance care plans will differ based on your UK region and organisation. Familiarise yourself with the policy for this within your own work setting and/or seek advice from a colleague with experience in this area.

The advance care plan should be shared with anyone involved with the individual’s care including:

The individual

Those important to the individual

Community provider

Out of hours health care provider

Emergency care providers

GP practice

Other attendees present during the advance care planning discussion

Reflective activity

  • Can you think of circumstances that would require an individual’s advance care plan to be updated?

Updating an advance care plan

It might be necessary to refresh or update an advance care plan if circumstances change. Here are some occasions when it may be necessary to consider amending an individual’s advance care plan:

  • if the wishes or preferences of the individual change, for example what treatment they might like to receive.
  • if the health of the individual changes or deteriorates suddenly.
  • if the cognitive capacity of the individual changes or fluctuates.
  • if local policies, procedures, or guidance changes.
  • if an individual is clearly entering the end-of-life stage, it is appropriate to review their advance care plan with the dying individual and/or those important to them.

Implementing and recording changes

If changes are made to an advance care plan, it is important that they are updated across electronic care records and paper systems. This means the updated version should be shared with the health and social care professionals outlined previously.

Outdated copies of the advance care plan should be archived or destroyed in line with your organisations procedures and replaced with up-to-date version which is clearly numbered and dated.

In the video below, Community Nurses discuss some of the practicalities of the advance care planning process.