What is Advance Care Planning (ACP) in Health and Social Care

What is Advance Care Planning (ACP) in Health and Social Care?

Person-Centred Care

Care Learning

3 mins READ

Advance Care Planning (ACP) is essential for ensuring person-centred care in the health and social care sectors. It involves discussions and plans about future health care preferences.

These plans become crucial when an individual can no longer make decisions for themselves. Let’s break down what ACP is and why it’s important.

What is Advance Care Planning?

Advance Care Planning is a process where individuals discuss and document their preferences for future care. This includes any treatments they would or would not like to receive. It’s particularly important for people with long-term conditions, older adults, and those approaching the end of life.

Why is ACP Important?

ACP ensures that individuals receive care that aligns with their values and wishes. It respects their autonomy, even when they cannot voice their opinions.

Key Components of ACP

Several key components form the basis of ACP:


The first step in ACP is a discussion. This typically involves the individual, family members, and health or social care professionals. The goal is to understand the individual’s values, beliefs, and wishes.


After discussions, the preferences should be documented. This serves as an official record. The documentation can include specific wishes about treatments, care settings, and other preferences.


ACP is not a one-time activity. Regular reviews ensure that the plan remains relevant. Life circumstances and health conditions can change, making ongoing updates crucial.


Sharing the documented plan with relevant parties ensures everyone involved in the individual’s care is aware of their wishes. Key parties can include family members and various healthcare providers.

Elements of an ACP Document

An ACP document can include several elements. Understanding these helps ensure comprehensive planning.

Preferred Place of Care

The document can specify where the individual prefers to receive care. This could be at home, in a hospice, or in a hospital.

Preferred Treatments

Individuals can outline which treatments they would like to receive or avoid. This might include preferences about life-sustaining treatments like ventilators or resuscitation.

Health and Personal Care Choice

Specific choices about personal care, such as bathing and eating preferences, can also be included. These details ensure comfort and dignity.

Emergency Contacts

Contact information for people who should be informed about health changes or crises can be documented.

Legal Considerations

Legal elements such as appointing a Lasting Power of Attorney (LPA) for health and welfare can also form part of the ACP. This ensures that a trusted person can make decisions on the individual’s behalf if needed.

Professionals Involved in ACP

Various professionals play roles in ACP:

General Practitioners (GPs)

GPs often initiate ACP discussions. They have a comprehensive understanding of the individual’s medical history.


Nurses frequently play a key role in ongoing discussions and reviews. They often have a close relationship with patients, making them well-placed to discuss sensitive topics.

Social Workers

Social workers can help address social care needs and ensure the plan covers all aspects of the individual’s life.

Specialist Palliative Care Teams

These teams are vital for individuals with life-limiting conditions. They offer expertise in managing symptoms and quality of life.

Legal Advisors

Legal advisors can help with the formal aspects, such as creating a Lasting Power of Attorney.

Benefits of Advance Care Planning

ACP offers numerous benefits:

Person-Centred Care

ACP ensures care is tailored to the individual’s specific wishes and values.

Reduced Anxiety

Knowing that their wishes are documented can reduce anxiety for both individuals and their families.

Improved Communication

ACP fosters open communication among the individual, their family, and healthcare providers.

Avoiding Unwanted Treatments

With clear instructions in place, unnecessary or unwanted treatments can be avoided.

Better Resource Use

Healthcare resources can be better allocated when individuals’ preferences are known, often reducing hospital admissions and emergency care.

Potential Barriers to Effective ACP

Despite its benefits, ACP faces several barriers:

Lack of Awareness

Many people are unaware of ACP and its benefits.

Reluctance to Discuss

Both individuals and families may hesitate to discuss end-of-life care preferences due to the sensitive nature of the topic.

Time Constraints

Healthcare professionals often struggle with time constraints, limiting their ability to engage in thorough ACP discussions.

Documentation Challenges

Properly documenting and sharing the ACP can sometimes be challenging, leading to breakdowns in communication.

Overcoming Barriers

To overcome these barriers, various strategies can be employed:

Education and Training

Raising awareness through education and training for both the public and healthcare providers is crucial.

Clear Communication

Encouraging open and honest communication helps in overcoming reluctance.

Dedicated Resources

Allocating dedicated time and resources for ACP discussions can improve the process.

Technology Use

Using electronic health records (EHRs) for documenting and sharing ACP can streamline the process.


Advance Care Planning plays a significant role in health and social care. It ensures that individuals’ wishes are respected even when they can’t communicate. By involving key professionals, documenting preferences, and regularly reviewing the plan, ACP achieves comprehensive and person-centred care.

Despite challenges, the benefits of ACP make it a cornerstone of compassionate and effective healthcare delivery. So, start the conversation today, to ensure your future care aligns with your wishes.

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