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Personalised Care and Support Planning
Why is Personalised Care and Support planning (sometimes called advance care planning) so important?
This is a voluntary process of person-centred discussion between an individual and their care providers about their preferences and priorities for their future care. These are likely to involve a number of conversations over time and with whoever the person wishes to involve. When advance care planning is done well, people feel they have had the opportunity to plan for their future care. They feel more confident that their care and treatment will be focused on what matters most to them in a personalised, holistic way and helps them to live as well as possible. A person must have mental capacity* to make an advance care plan (* for more information please visit Gov.uk). As part of the process a person might choose to describe the type of care they would like at the end of their life. Personalised care plans should be documented in a person’s electronic record to avoid a person having to repeat relevant information to the healthcare professionals involved in their care. Plans can be adapted at any time following further discussions.
In this video, Tony Bonser describes his experience of the benefits of Advance Care Planning when planning his son’s funeral .
The benefits of advance care planning – Macmillan Cancer Support
MyWishes is a free to use, ‘tech for good’ platform. It will empower you to write your Last Will & Testament, safeguard your Digital Legacy, plan your Funeral, curate a Bucket List, leave Goodbye Messages and make plans for your future health and social care within an Advance Care Plan.
Top tips to setting up and managing a supportive / palliative care register in primary care
Personalised care means people have choice and control over the way their care is planned and delivered, based on ‘what matters’ to them and their individual strengths and needs. This happens within a system that supports people to stay well for longer and makes the most of the expertise, capacity and potential of people, families and communities in delivering better outcomes and experiences when unwell.
This site draws on the expertise of NHS Wales, the National Council of Palliative Care, Hospice UK as well as other organisations from across the country to help you start thinking about your Advance Care Plan.
This short film based on 50 interviews, highlights the importance of what matters conversations in the delivery of effective patient care from the perspective of professionals, and gives examples from clinical practice of how this approach can be incorporated into busy daily practice.
Planning for the future – simple 5-step guide to Advance Care Planning to help ensure you receive the care you want when you need it.
Use the EPaCCS (Electronic Palliative Care Coordination System) mechanism for recording conversations and any changes in care plans using coding in Electronic Patient Records (EPR).
(link to share information)
Advanced Care Planning Support section for members of the public and carers.
Guidance for symptom control of common symptoms and conditions in PEOLC
Practical guide for staff – Best Practice Guide for life Limiting Conditions
Resuscitation Council’s guide to CPR Decisions
Resuscitation Council’s guide for patients and those close to them
Anticipatory Clinical Management Planning guidance including DNACPR
unified DNACPR Lilac Form
short videos
Position Statements on ReSPECT
Practical support for staff and families when talking about death and dying
https://www.nhs.uk/conditions/end-of-life-care/changes-in-the-last-hours-and-days/
Practical support for staff and families when talking about death and dying
Practical support for staff and families when talking about death and dying
Practical support for staff and families when talking about death and dying
https://www.mariecurie.org.uk/help/support/terminal-illness/preparing/final-moments
An advance decision (sometimes known as an advance decision to refuse treatment, an ADRT, or a living will) is a decision you can make now to refuse a specific type of treatment at some time in the future.
This short film based on 50 interviews, highlights the importance of what matters conversations in the delivery of effective patient care from the perspective of professionals, and gives examples from clinical practice of how this approach can be incorporated into busy daily practice.
Planning for the future – simple 5-step guide to Advance Care Planning to help ensure you receive the care you want when you need it.
Serious Illness Conversation Guide : Use this to talk to patients about their goals and values, set up the conversation, assess the patient’s illness understanding and information preferences, share prognosis, explore key topics and document the conversation
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Education to support Care Planning
The End-of-life Care for All (e-ELCA) programme is an elearning library which provides resources to enhance the training and education of the health and social care workforce so that well-informed high-quality care can be delivered by confident and competent staff and volunteers to support people wherever they happen
e-ELCA 01: Advance care planning
e-ELCA 02: Assessment in end-of-life care
e-ELCA 03: Bereavement
e-ELCA: Dementia
e-ELCA Family Support Module
e-ELCA 02: Assessment in end-of-life care
e-ELCA : DNACPR
Skills for Health and Skills for Care Core Skills Education and Training Framework for End of Life Care.
ACP Support – no login required
A resource for health care providers to provide training in Advance Care Planning (ACP) – Seven training units can be used on their own following introduction. These comprise of learning objectives, videos and reflection for staff to complete. Each unit will take approximately 20-30 minutes to complete.
ACP training aimed at Community & District Nurses
ACP Support section for members of the public and carers.