2.9 Identify how an advance care plan can change over time

This. guide will help you answer 2.9 Identify how an advance care plan can change over time.

An advance care plan is a written record that explains a person’s wishes about their future care. It can cover medical treatment, day-to-day care, and personal preferences.
The plan is often prepared when a person still has the capacity to make decisions. Capacity means having the ability to understand, retain, and weigh information, and to communicate a choice.

The aim of an advance care plan is to make sure the person’s voice is heard even if they cannot speak for themselves later. Health and social care professionals use the plan to guide care that respects the person’s values, beliefs, and priorities.

Advance care planning follows the principles of person-centred care. This means putting the person at the centre of all decisions about their care.

Why Advance Care Plans Can Change

An advance care plan is made at a certain point in someone’s life. Lives change over time. Health issues, family situations, and personal views can all shift. These changes can affect what a person wants in their care.

A plan must remain relevant. If it does not reflect the person’s current wishes or needs, it may not support their best interests.
Reviewing the plan at regular intervals or after major life events helps keep it up to date.

Common factors that lead to changes include:

• Changes in health condition
• New treatment options becoming available
• Moving to a different living environment
• Changes in family or support network
• Shifts in personal beliefs or values

Changes in Health and Medical Condition

Physical health changes are one of the most common reasons for amending an advance care plan.
Health can improve, decline, or become more complex over time.

Examples:

• A person diagnosed with a terminal illness may decide to focus on comfort care rather than aggressive treatments.
• An individual recovering well from surgery might request more active interventions in the future.
• A person living with dementia may reach a stage where earlier decisions about certain treatments no longer apply to their current needs.

As conditions progress, different care options may be discussed. Treatments available now may not be available when the original plan was made.

Impact of New Medical Treatments or Technology

Medical options for treatment and care often change. A treatment that was not possible or acceptable years ago could become a realistic choice.

For example:

• New pain relief methods might make certain procedures more comfortable.
• Improved home care technology can allow someone to stay at home for longer rather than going into residential care.
• Experimental drugs might later become approved and safe.

When new choices arise, a person may wish to update their preferences to include or exclude them.

Change in Living Arrangements

Where someone lives can influence their care preferences.
Moving to a new location, such as a care home, supported living setting, or into a family member’s home, may mean a different routine and available services.

For instance:

• In a care home, certain equipment and support might be available on-site, changing what is possible.
• If moving in with relatives, there may be more options for home-based care.
• Moving closer to specialist hospitals could make access to certain treatments easier.

These changes could make some parts of the original plan less relevant or add new possibilities.

Family and Relationship Changes

Family structures can shift over time. Relationships may end, new ones may form, or main carers may change. This can affect both emotional support and practical care.

Examples:

• The person who was the main decision-maker or advocate may no longer be available.
• A new partner or family member may be willing and able to help with care needs.
• Children may grow up and be in a position to support care more actively.

Such changes can prompt updates in who is consulted or involved in care planning.

Shift in Personal Values or Beliefs

A person’s values, beliefs, and outlook on life can change. These shifts can be influenced by new life experiences, illness, or conversations with others.

Changes may include:

• A stronger focus on quality of life rather than prolonging life.
• A change in religious or cultural beliefs affecting treatment choices.
• A new outlook on independence and daily routines.

Since advance care plans aim to reflect the person’s wishes, any shift in personal priorities should lead to a review.

Legal and Policy Changes

Laws and health care policies sometimes change. These changes might affect what can be included in an advance care plan or how it must be recorded.
For example, forms may need to be updated or certain decisions may need to meet new legal criteria.

Keeping the plan aligned with current regulations helps both the person and care providers.

Updates Following a Hospital Stay

A hospital stay can change someone’s needs and wishes. Some may realise they prefer less medical intervention. Others may feel they want to try new therapies that became known during their stay.

Health professionals might recommend revisiting the plan after significant hospital care because it can highlight new priorities or limits.

How an Advance Care Plan Can Be Updated

Updating an advance care plan can be straightforward. It can involve adjusting small details or rewriting parts of the plan entirely.

Key steps:

• Discuss changes with the person while they have capacity.
• Record updates in writing.
• Share the updated plan with all relevant health and care workers.
• Date and sign the new version.
• Make sure old versions are clearly marked as no longer current.

Even small adjustments should be documented to prevent confusion.

Keeping the Plan Ongoing and Relevant

An advance care plan works best when regularly reviewed. Reviews can be set by time or triggered by events.

Examples of regular review points:

• Every six months for those with unstable health.
• Annually for those in stable condition.
• After diagnosis of a new condition.
• After any major medical event or surgery.

Consistent reviews mean the plan reflects the person’s present wishes and maintains its use as a guide for care.

How Care Workers Can Support Plan Changes

Care workers play an important role in recognising when a plan may need to be reviewed.
Working closely with the person and observing their daily life can reveal signs that preferences or needs have changed.

Support may include:

• Noticing any changes in the person’s physical or mental health.
• Listening when the person talks about their wishes for the future.
• Speaking to family or advocates if appropriate.
• Suggesting a formal review at the right time.

Workers should follow organisational policies and involve the relevant professionals in the review process.

Communication and Recording Changes

Any change to an advance care plan should be clearly recorded and communicated to all relevant people.
Failing to do this can result in care that does not match the person’s wishes.

Good practice includes:

• Using clear, simple language in records.
• Distributing updated copies promptly to the care team, GP, and family where relevant.
• Confirming that everyone is working to the same version of the plan.

Accurate communication avoids mistakes and supports consistent care.

Emotional Impact of Changing the Plan

Making or amending an advance care plan can be an emotional experience. Facing discussions about future illness or end-of-life care can be difficult for the person and their loved ones.

Workers supporting the discussion should:

• Allow time for the person to think about changes.
• Listen without judgement.
• Offer reassurance that reviewing the plan is normal and positive.
• Encourage the person to involve trusted family or friends.

Supportive conversations build confidence in the process.

Advance Care Plans and Mental Capacity Changes

Mental capacity can change over time. Someone may be able to make decisions now but lose that ability later due to illness or injury.

If a person still has capacity, they can review and alter their plan at any time.
If they lose capacity, the plan can guide others in making best interest decisions. Any changes would then follow legal rules, usually through consulting family, advocates, or using a legal proxy such as a Lasting Power of Attorney for health and welfare.

This makes early and regular reviews important while the person can fully express themselves.

Recording Reasons for Changes

When updating an advance care plan, it is helpful to record the reasons for change. This helps others understand the background and respect the decision.

For example:

• “Decision changed after trial of new medication improved comfort levels”
• “Family member who was main carer has moved away”
• “New diagnosis given by consultant on [date]”

Documenting the reasons supports transparency and prevents misunderstanding.

Encouraging Ongoing Involvement

A living plan works best when the person feels ownership of it. Encourage them to revisit it often and treat it as a flexible guide rather than a fixed statement.

This attitude reduces anxiety, as the plan can move with their life changes.

Final Thoughts

An advance care plan is a valuable document that gives people control over their future care. It is not a one-time decision. It should be updated to match changes in health, care options, living arrangements, relationships, or personal values.

Regular reviews keep the plan relevant and effective. Health and social care workers can help by listening to the person, recognising changes in their situation, and supporting the review process. Clear communication ensures everyone involved is working from the latest version.

By treating the plan as flexible and current, we make sure it always reflects the person’s voice. This means their care will align with their wishes even if they cannot speak for themselves. In health and social care, this respect for the individual’s decisions is one of the most important parts of dignified, person-centred support.