Rose had decided that she wanted, as far as possible, to manage her multiple conditions with medications and that she did not wish to have any invasive treatments or interventions. She appreciated that her conditions were not curable and were liable to progress. In NHS Scotland, planning for the future is normally referred to as Advance Care Planning. It involves talking about what you do or do not want to happen to you in the future regarding any care that you might need. The Good Life, Good Death, Good Grief website suggests that issues to think about are:
- granting power of attorney
- thinking about an Anticipatory Care Plan
- talking to your healthcare professional and those important to you about what you want in the future
- thinking about organ donation
- deciding on whether you want a DNACPR order implemented
- any medical treatments that you may not want
Advance care planning
Advance care planning is the term most commonly referred to in end of life care, although it does incorporate the writing of wills or “Living Wills” now known as advance directives or advance decisions which can be done by the well person early on in life to plan for what may happen at the end of life. Anticipatory care planning is more commonly applied to support those living with a long term condition to plan for an expected change in health or social status. It also incorporates health improvement and staying well (Scottish Government, 2010. Anticipatory Care Planning: Frequently Asked Questions).
Rose and her community nurse had drawn up an Anticipatory Care Plan. She had read through the information on Advance and Anticipatory Care Planning provided by the nurse and knew what was involved.
Based on their conversation, the community nurse completed an anticipatory care plan for Rose, with a DNACPR form. The format for anticipatory care plans may vary slightly, depending on the health board or clinical area. Useful suggestions on how to develop a plan can be found at:
- Good Life, Good Death, Good Grief – Making an Anticipatory Care Plan
- NHS Highland Anticipatory Care Patient Alert (ACPA) Form Pack (PDF)
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Rose told her younger sister what she had done but asked her not to tell other family members, as she did not want to upset them.
ROSE’S Anticipatory Care Plan
Patient name: Rose Lovie
Title: Miss
DOB: 08/09/1935
Other named professional: Elaine Thomas, Community Nurse
Next of Kin: Alison McPhee
Title: Mrs
Relationship: Sister
Patients medical information: Heart Failure (second to aortic stenosis)
COPD
Renal problems
Key Action Points: Does not want any invasive treatment
DNACPR discussed and form completed
Sister has power of attorney for all matters
Would like end of like care to be provided in hospice
Other relevant information: Lives alone. Carers twice daily to provide support with meals.
