Planning in Care Homes
Dr Erna Haraldsdottir
Advance Care Planning (ACP)
• Advance Care Planning –
“…is a process of discussion in which individuals,
their care providers and often those close to
them, make decisions with respect to future
health or personal and practical matters of care”
Advance Care Planning (SLWG3) Living and Dying Well 2009
Components of ACP
Legal - a will or advance decision related to
refusal of medical treatment
Personal - preferred place of death/advance
Medical - advance decisions
Why ACP in Care Homes ?
Increasing impetus on autonomy and choice in Government Health and Social
Documents specific to the Care Home setting
End of Life Care for People with Dementia 2009 (England)
Making Good Care Better 2006 (Scottish Executive/SPPC)
Living and Dying Well 2008 section (point 34 p 14/ action 15)
Better Care Every Step of the Way. Report on the quality of palliative and
end of life care in care homes for adults and older people Care
Commission April 2009
One way to achieve patient-centred care and maintain patient
autonomy is to elicit their health values and preferences before they
lose their ability to state those preferences
One of five deaths occurs in care homes
ACP training in Care Homes funded by NES
• One day ACP Study Day designed and delivered in March 2010 in three
Geographical areas Grangemouth, Edinburgh, Glasgow for senior staff in
• 150 participants attended one of the 3 days.
Programme consisted of:
• Power point presentations
– ACP in the context of current health care delivery
– What is ACP ? key component, how is it done? who does
• Interactive workshops
– Exploring participants’ experience and perception of ACP
in own practice
– Case studies to demonstrate the use of ACP in practice.
ACP in Care Homes current practice,
challenges and benefits
• Participants were asked to consider 3 questions in
relation to ACP in order to gather their experience,
provide the opportunity to share this experience as
well as discussing the benefits and challenges of ACP.
What is your experience/role in
relation to ACP?
• Very little or no experience
• I am the designated person who approaches
residents and discusses with them issues related to
• Some stated they had done APC once and others
stated they were doing ACP as part of the care plan
and in relation to LCP.
Current practice of ACP
• Currently include ACP plan into care plans on
admission and review regularly.
• In the process of including ACP into the care plan.
• Actively progressing the palliative care approach
within the care home including preparing resident
and family for death and documenting wishes but
would not label it as ACP.
• Lack of ACP planning and end of life care still being
led by crisis and discussion and formal planning
could be improved in the care homes setting.
• Indication that current care plan was not suitable for
inclusion of ACP and needed to be changed .
Current practice of ACP cont.
• Concerns around not knowing the legal status of ACP
document as part of care plan for a resident
• Document in place but not filled out properly
• Using DNR forms
• When the resident was in the care home setting it
was already too late for ACP discussion to happen
and this needs to be done prior to admission to the
• Further training is needed for successful
implementation of ACP and LCP.
• Support from local GP practices varied
• GP involvement is essential.
Benefits of ACP
• Enhance communication and increase the quality of the care,
allowing resident to state their wishes leading to increased
autonomy and control over their care and dignified care at end
• Decrease anxiety and distress for staff, resident and the family
• ACP enhances teamwork, inter discipline communication
• Increase staff confidence when providing end of life care
• Leads to better job satisfaction by staff when providing end of
life care as a result of increased confidence and good team
• Enhance family involvement in the care and help families in their
Challenges of ACP
• Involves sensitive discussion needing advanced
– Communication challenges included:
• How and when to start ACP discussion
• Resident and family being reluctant to discuss
issues related to death and dying and this being a
• Cognitive impairment of the residence
• Conflicting views within the family.
Challenges of ACP cont.
• Lack of clarity about legal and medical status of ACP
• Environmental issues
• Lack of private rooms for the discussion to take
• Residents and family members need to be informed
about the ACP process and its purpose if it were to
be implemented systematically into a care home.
• Successful implementation of ACP required adequate
resources and training opportunities for all staff.
Benefits and challenges of ACP in Care
• Feedback from participants regarding the potential
benefits and challenges of ACP in health care was
reflective of the research in this area demonstrating
the challenges of implementing ACP in the Care
Home setting (Froggatt et al 2009).
Participants’ Evaluation of the Study Day
Participants’ comments about the Study
• Helped to clarify specific issues related to ACP
– Legal issues
– How and when to start ACP discussion and issues
related to documentation.
• Provided the opportunity to reflect specifically on issues
related to implementation of ACP in own clinical area,
including challenges to the implementation and how to
go about these
• Enhanced understanding of the benefits of ACP and how
they felt the day had enthused and motivated them in
relation to implementing ACP in their own clinical setting
• Participants also commented positively on the
opportunity to network and share experience.
• Feedback from the participants endorses research
evidence highlighting the need to ensure that all
levels of staff are appropriately trained and
supported to undertake the implementation of ACP
(Froggatt et al 2009).
Participants said as a result of the study
day they would…
• Now have increased commitment to making ACP
part of their own practice and to be proactive in
developing ACP within their own clinical area.
• Be more confident and able to have ACP discussion
with their residents and family members and would
take the time to do so.
• Have discussions with other members of staff within
their service about ACP both informally and through
formal meetings including speaking to their local GPs
and district nurses as well as service managers.
Participants said as a result of the
study day they would…
• Teach ACP to other members of staff through in-
house training sessions and look for further external
• Review their documentation and include ACP
discussion into their current Care Plan
• Advocate that ACP would be implemented routinely
in their workplace and would consider ways of
informing residents and their families about ACP in
Influencing change within practice
• Many of the participants felt that they would be in a position
to influence implementation of ACP in their work place,
reflecting that 59% of participants were in a managerial role.
• Ways of influencing practice were identified as:
– offering in-house training
– seeking external training opportunities
– cascading information both informally and formally
– role modelling ACP
– communicating with local GP practices and local specialist
Palliative Care services to gain support
– informing residents and families about ACP
Further support needed
• Further education
– more Awareness Raising Study Days followed by regular updates
• Awareness raising and training for GPs
– their support was deemed vital for successful implementation
– sharing of experience and knowledge
• Access to education material was seen as supportive
– participants intended to make use of the web resource designed
to support the Awareness Raising Study Days.
The team who designed, delivered and
organised the training
Dr Erna Haraldsdottir, Head of Education
Jackie Higgins, Lecturer in Palliative Care
Pam Clark, Lecturer in Palliative Care
Dr Fiona Downs, Consultant in Palliative Medicine
Dr Gill Foster, Associate Specialist in Palliative Medicine
Gail Allan, Community Clinical Nurse Specialist in Palliative Care
Lesley Whitelaw, Deputy Matron
Catherine Haggerty, Education Administrator
Fiona Mulvany, Hospice Secretary
Doreen Mullen, Hospice Secretary
Mari Alcorn, ITIM Manager
We wish to thank
Liz Travers, NES Education Project Manager
Susan Polding-Clyde, Nurse Consultant for Older People in Care Homes
David Rennie, Private Care Sector Workforce Initiative Manager
The participants who attended these events and shared their ACP experiences,
anxieties and hopes for the future
• Froggatt K, Vaughan S, Bernard C, and Wild D (2009) Advanced care
planning in care homes for older people an English perspective Palliative
Medicine 23 332-338
• Living and Dying Well; A national action plan for palliative and end of life
care in Scotland, Scottish Government Publication, 2008
• The Development and Delivery of an Education Event and Education
Resource to Support the Implementation of Advance/Anticipatory Care
Planning in Generalist Care Setting. Strathcarron Hospice/NHS Education
for Scotland, February 2010
• Web Resource; http://www.strathcarronhospice.org/education.html
• ACP, in all health care settings has been endorsed by the
• Steps should be taken to ensure that patients in care homes
benefit from this approach (Scottish Government 2008)
• Implementing ACP in Care Homes
– What opportunities does ACP offer Care Homes?
– What are the challenges in implementing ACP in Care Homes and how
can these be addressed ?
– What elements will facilitate implementation of ACP in Care Homes?