Anticipatory care planning in three questions

Dr Andrew Mackay, St Triduana's Medical Practice

St Triduana's Medical Practice – Edinburgh

The problem

When the Care Home Enhanced Service started in Lothian in 2008 our 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.

The Bright Idea

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. The questions asked are, how would the resident like to be treated in the event of:

  • a sudden collapse?
  • an infection not responding to antibiotics?
  • an inability to eat and drink due to illness?

There is a similar alternative form that is used to form the basis of a discussion with residents who do have capacity. We have also developed a simple guide for those filling out the questionnaire and another for staff helping to facilitate the process. 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. 

The impact


Patient and families wishes are taken into account. It also gets families talking about these issues.


GPs find it useful because it's such a clear plan, and very specific – it answers the questions you want to know, like what are the patient's wishes and do I need to admit this patient? Care home staff find it a useful tool to establish what's expected of them, in terms of patients going to hospital.

Read more bright ideas and submit your own, ideas submitted are automatically considered for the next bright ideas awards.

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