Anticipatory care planning in three questions

Anticipatory care planning in three questions; does it work and do people like it?Andrew-Mackay

Dr Andrew Mackay, St Triduana`s Medical Practice, Edinburgh

When the Care Home Enhanced Service started in Lothian in 2008 our practice, St Triduana’s Medical Practice, had almost 300 care home residents that required anticipatory care plans (ACPs). It was clear that some of the ACPs being created contained vague and general statements that were unlikely to significantly impact on patient care. There was already good evidence from the work in Nairn and elsewhere that high quality ACPs could reduce inappropriate admissions. However the process to create those plans involved a lengthy face to face meeting with medical or nursing staff.

We thought that a simple and brief form that could be given out by care staff would not only make this daunting task more efficient but allow the care plans created to give specific and meaningful guidance to doctors having to attend to the residents when seriously ill.

The questionnaire we designed is given to relatives of new care home residents who lack capacity to make decisions concerning their welfare. It asks the relatives to give their views on how they think the resident would like to be treated in the event of a serious illness. A sudden collapse, an infection not responding to antibiotics and an inability to eat and drink due to illness are the three scenarios presented. There is a similar alternative form that is used to form the basis of a discussion with residents who do have capacity.

The information from the forms is then combined with personal data and information on function status to create a detailed and robust ACP. This is recorded in an electronic Key Information Summary (KIS) that is shared with the out of hours GP service, ambulance control and secondary care. The KIS also includes a medical history, drug history, resuscitation status and next of kin details. A copy of this KIS is printed off, discussed with care home staff and added to the resident’s notes.

Over the last year, funding from Marie Curie has enabled us to form a Steering Group and design and conduct a small project to evaluate the use of the questionnaire in two contrasting care homes in Edinburgh.  In particular, we assessed its effectiveness and acceptability and identified barriers and facilitators to its use.  We did this by conducting a prospective audit of acute clinical events over a six month period and by interviewing relatives care, care home staff and GPs.  We also invited 30 Lothian Unscheduled Care Service GPs to a focus group to discuss a range of scenarios that typically occur in a care home setting.

Our conclusions were that anticipatory care planning should ideally start before care home admission and be a coordinated, ongoing care process tailored to individual needs and embedded in the routine procedures of the care home.  Clear plans, recorded electronically, ensured most acute clinical events were handled appropriately. 58 out of 69 acute events were handled either in accordance with the ACP or appropriate decisions were made by out-of-hours doctors. The system was most vulnerable when protocol-driven decisions were made by NHS call handlers. 

The care planning process was broadly acceptable.   Some people found the document clear and helpful; others thought it needed to be modified.  Staff and relatives would welcome a brief explanatory leaflet about the process and the decisions to be considered as well as information from staff.

We have followed this project up by revising the questionnaire, developing a simple guide for those filling out the questionnaire and another for staff helping to facilitate the process. We have stuck to the fundamental principal of a single sheet questionnaire with three questions. 

We have discussed ways in which a review of the ACP can be incorporated into the routine relative review process by care home staff. The Lothian Health and Social Care Integrated Joint Board is currently considering whether to fund a roll out across the Lothian care home sector.

Quotes from interviews with GPs, Relatives and Care Home Staff

Now we’re doing KISs I find it really easy because it’s really easy to transfer it over.  I work in out-of-hours as well and I think it’s really useful because it’s such a clear plan, it’s very specific – it answers the questions you want to know, like what are the patient’s wishes – do I need to admit this patient?  That’s what you need to know.  And what are the families’ wishes?  And it’s quite nice I think because it gets families thinking about these issues too (GP)

Its very self-explanatory, it’s set out in very detailed terms what people will be admitted for, what they wont be admitted for, and people can decide at the time they’re coming in because usually that’s the best time to establish what’s expected of us as well, in terms of them going to hospital (Staff, Care Home 2)

I think you need it because at the end of the day, they’re your relative and they need a spokesperson and I just know how my mum felt about life (Relative, Care Home 2)

I think its an excellent idea.  She had all this at her last care home anyway, so I’m quite familiar with it.   I know it can be upsetting for some people, to be asked beforehand, but you do really need to know.  So, I totally agree with this. (Relative, Care Home 1)

Ideal anticipatory care plans cannot be achieved with three questions alone. However, this questionnaire has formed the basis of robust and specific anticipatory care plans in a care home population that improve management of acute events and are acceptable to those that use them.

For more information please contact Dr Andrew Mackay at

Download the form and useful documents here:

Leave a comment

* indicates mandatory field
* *

You have characters left.

Page comments

User comments and ratings (5)

Liz fisher

I will discuss with my GP partners as these documents look good and we may ne able to update our forms accordingly Thanks

Liz fisher

I will discuss with my GP partners as these documents look good and we may ne able to update our forms accordingly Thanks

Monica Walsh

Most practically useful documents I have seen in a long time - thank you for sharing this!

Jo Withers

This looks very useful: many thanks for sharing.
Did you document LPA for health and welfare anywhere?

Andrew Mackay

Hi Jo
Thanks for your comment. The new patient information sheet includes a section for welfare guardian/power of atorney. He phrases in Scotland are slightly different. Because these are all
word documents you can edit them to fit local terminology.

The item has been added to your basket.

Continue shopping

Go to basket

This item is out of stock.

Continue shopping

The item is out of stock.

Yes Continue shopping

An error occured adding your item to the basket:

Continue shopping