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Consider whether the patient has uncertain prognosis or is nearing end of life, and would benefit from ACP discussions

Opportunities for ACP conversations could include:

  • Change in condition
  • Change in treatment
  • Admission/discharge from hospitals
  • Admission to a care home
  • Patient or family seeks discussions
  • As part or management plan or treatment plan reviews

Tools that can support identification of patients with uncertain recovery/poor prognosis are:

Have compassionate conversations to support ACP

Consider the following when having conversations to discuss uncertain recovery/poor prognosis in relation to ACP:

  • Check the patient's understanding and consent for the conversation
  • Reflect on recent trends
  • Reflect on treatment effectiveness
  • Acknowledge uncertainty
  • Ask 'what matters to you?'
  • Listen compassionately to concerns, wishes and preferences
  • Reflect on future goals in relation to future deterioration or crisis
  • Agree ongoing management plan
Consider offering the Thinking Ahead – guidance for patients and families leaflet.

Advise the MDT/team and document the outcome of the ACP conversation

  • Discuss outcome and recommendations from ACP discussions at MDT and GSF meetings
  • Guidance on the completion of Treatment Escalation Plan (TEP) and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT)
  • Guidance on information on S1 and making this accessible to out of hours

Transfer information to support continuity of care

  • Any Information that supports advance care planning must follow the patient on any transfer of care
  • Consider completing Treatment Escalation Plan (TEP) or Recommended Summary Plan for Emergency Care and Treatment (ReSPECT)
  • Communicate with key healthcare professionals on any transfer of care

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