Planning for Care

A Power of Attorney (PoA) is a legal document that lets someone else make decisions for you if you can’t do it yourself. The person you choose to make these decisions is called your “attorney.” You can ask anyone you trust to be your attorney.

There are two main types of Power of Attorney:

1. Welfare Power of Attorney – This allows someone to make decisions about your health and well-being.
2. Financial Power of Attorney – This allows someone to make financial decisions for you.

You can choose different people for each type of PoA, or the same person can handle both. If you have more than one attorney, you can choose if they have to make decisions together or can make them on their own.

You decide when your Financial Power of Attorney starts, but your Welfare Power of Attorney will only begin if you can no longer make decisions yourself. This is sometimes called “losing capacity”.

Choosing someone you trust to be your Attorney is critical. It doesn’t automatically need to be family member – you could pick a friend, a lawyer or an advocate (although that may involve additional costs).

You can also add in a safety mechanism such as a clinical sign off for lack of capacity for your Welfare PoA. This means that you will still be in control of making all decision until you are no longer able to.

You can also choose when you want your attorey to start helping with finanical issues, or when they should stop.

Remember if you have concerns you can report these to the Office of the Public Guardian.

After setting up your PoA, it’s important to talk with your attorney so they understand what you want if you can’t make decisions for yourself later on. You might want to write down your wishes in a Future Care Plan.

Let your doctors and health professionals know who your attorney is, so they can contact them if needed.

To get a PoA, you need to choose someone to act on your behalf while you are still able to make decisions.

Here’s how to get started:

1. Talk to people close to you about why you want a PoA.
2. Decide who will be your attorney. You can choose one person for welfare decisions and another for financial decisions.
3. Once you’ve chosen, you need to register the papers with the Office of the Public Guardian.

Because it’s an important legal document, it’s a good idea to get help from a lawyer or solicitor to make sure everything is done properly.

A solicitor could be instructed to come to the hospital – this can happen pretty quickly. There may be a conversation between the solicitor and the medical team about who should sign the capacity certificate. Then an application needs to be made to fast track the PoA.

However, you need to be realistic, about the time left that someone has to live.

Another option would be a Future Care Plan; this would be beneficial so that everyone can contribute to the conversation. This means even if the PoA does not happen, the professionals will have a guide on the person’s wishes, and family/friends have a chance to discuss this with the person as well.

Consider if a solicitor could also complete a Will at the same time (this can happen at any time however the person must still have capacity to sign the document).

You can do it yourself – you may find a template online or stationary firms e.g. a pack from WH Smiths (check that it is Scottish). It is slightly cheaper if you go through a firm online (do your research) but still incurs a fee. In all instances you will need to pay for a certificate of capacity (GP/solicitor) and the registration fee with the Office of Public Guardian.

You can use Law Society of Scotland website to find a solicitor.

An impartial person must witness you and your Attorneys signing of your PoA. You cannot witness your Attorneys’ signatures, and they cannot witness yours.

Anyone can check on the Public Register Scotland: Public registers (publicguardian-scotland.gov.uk), there are 2 different emails for enquiries – one for PoA and one for Guardianship.

There are lots of changes you must tell the Office of the Public Guardian about. There may be costs associated with this. Visit their webpages for more information.

If you need to update either the grantor or attorney’s address then you can do this via a form sent to the Office of the Public Guardian.

If you wish to change who your Attorney is then you will likely need to make a new PoA. This will come with an additional cost.

Appointment as Attorney will continue until:

• if concerns have been raised – the Office of Public Guardian will investigate
• the Granter revokes/cancels the PoA 
• the Attorney resigns
• the Granter dies
• bankruptcy of the Attorney

Many people think that if they lose the ability to make decisions, their family can automatically help. But unless you’ve set up a PoA, your family can’t make decisions for you.

Without a PoA, the court will have to choose someone to be your “Guardian,” which can take a long time and be expensive.

Carer Information Scotland have more information on the guardian process.

You can choose anyone to be your Attorney so long as they are over 16. You can appoint either individuals or an organisation, such as a firm of solicitors, as your continuing (financial) attorney. However, individuals only may be appointed as welfare attorneys. The law says that someone who is currently declared as bankrupt cannot be a continuing attorney.

Anyone can be appointed to act as your Attorney. Some solicitors may be willing to be an Attorney, however there would be a fee for this. It is unlikely that a Health or Social Care professional could be your Attorney, instead they may need to apply to become your Guardian which is a different process.

No. There is no requirement to notify them when you begin exercising your powers. Attorneys are responsible for informing relevant individual authorities e.g. banks, care homes etc. when they start acting on behalf of the Granter. More information can be found in the factsheet for attorneys.

A copy of the document is sent to the person who has applied for the POA (the granter) – it would be up to the person/family to make a copy of the document for the Attorney.

Check the PoA Document – the first step is to review the PoA document itself. It may:

• Specify how decisions should be made (e.g. jointly or independently).
• Appoint a lead attorney or provide a dispute resolution mechanism.
• Include guidance or preferences from the granter (the person who granted the PoA).

Seek Legal Advice – it’s wise to consult a solicitor experienced in PoA and adult incapacity law. They can:

• Clarify legal responsibilities
• Help interpret the PoA document
• Advise on next steps

Involve the Office of the Public Guardian (Scotland) -the Office of the Public Guardian oversees attorneys and can investigate concerns about how attorneys are acting. They can:

• Refer serious matters to the court.
• Offer guidance
• Investigate complaints

The powers that an Attorney has are detailed in the PoA document. If they have Welfare PoA and the person has lost capacity, the Attorney will be involved in discussion around what is going on, conditions, results etc. You cannot access medical records.

We would suggest engaging a solicitor to draft the Will and this should be done when person has capacity but there is no reason why you cannot support someone to do this, even if you may be a beneficiary.

It is not possible in Scotland for an Attorney to change someone’s Will, irrespective of whether the Attorney is trying to act in accordance with the person’s wishes and in good faith.

No, when person dies the PoA stops, it is only active when the person is alive. It is Important for people to arrange a Will and appoint an Executor.

“Losing capacity” means you can no longer look after your own financial and personal matters. This can happen because of health problems like dementia, a stroke, or other conditions. In Scotland, a person is an adult at 16 and can make their own decisions unless a doctor says they can’t.

Signs that someone has lost capacity include:

• Not being able to tell other people about the decisions they want made
• Forgetting decisions
• Not being able to act on decisions
• Not being able to understand or make decisions

If someone has lost capacity, then they cannot make a PoA. Instead, someone will need to apply for Guardianship – this could be a friend, family member or the Local Authority.

If assessed as not having capacity, and there is family, they can seek Guardianship not PoA, Local Authorities can also apply for Guardianship.

Depends on the level of capacity – mental capacity is the ability to make an informed decision based on understanding a situation, the options available, and the consequences of the decision. Just because someone is not able to make one decision, this does not mean they can’t make other decisions.

An assessment of capacity will be required to confirm this. 

Attorney’s should act on behalf on the Grantor, so it is important that everyone has had lots of conversations about what matters to individuals. These could be recorded in a Future Care Plan which the Attorney can use to help make decisions at a later date.

If anyone has concerns about the Attorney and decisions that are made they can refer it to the Office of the Public Guardian.

There is a cost for registering a PoA. There may be other costs like legal fees or getting a “certificate of capacity”. However there may be financial help available to cover these costs. You can ask Citizens Advice Scotland website for more details.

You can apply for exemption of the Office of the Public Guardian fee or Legal Aid towards a solicitor drafting a PoA (need to check they offer this service) – both have criteria you need to meet.

You may also be able to get a fee waived or reduced for your capcity certificate, however you would need to speak to your solicitor or GP.

You don’t need to use a solicitor to draft your documents, and this can reduce the cost. However because this is a legal process, if you have any anxiety about writing your own documentation, or unsure how to go about this, then we would recommend seeking legal advice.

Do not be afraid to contact various firms and enquire about charges, and remember to ask about Legal Aid if you think your are eligible. For more information on legal aid visit Scottish Legal Aid Board | Solicitors for Older People Scotland

Yes, some firms will offer a reduction for two people, the average is around £600+. You can also do this through an online firm which can be cheaper. Remember to shop around and do your research.

It does vary, but again you can apply for exemption for part fees (criteria applies) or check if you are entitled to Legal Aid. Guardianship has different fees for various parts of the process, and it also depends on the circumstances of the individual. Check the Public Office of Guardian (Scotland) website or give them a call if you need more information (01324678300 and press option 0).

“Continuing (financial) powers can be used by the attorney immediately after the PoA document has been registered with the OPG. If the PoA is only to be used in the event of your incapacity, it must clearly state that the powers are not to be used until this happens. You may wish to add a statement about who should make this decision about your incapacity” (Office of Public Guardian).

You cannot be a Financial Attorney if you have been declared bankrupt. It does not affect Welfare Powers.

If you were granted the powers before your became bankrupt then the Office of Public Guardian may remove these powers. In these situations we would recommend seeking legal and/or financial advice.

Financial Powers are in place as soon as they are registered with the Office of Public Guardian. Remember you need to inform organisations of Attorney status and evidence this. Consider – Is it time for an assessment of capacity to confirm this?

Yes, Financial PoA is activated right away and can be used when needed.

Scammers – POA wouldn’t affect this. Some banks may have other things set up for vulnerable customers – you would need to speak to the bank. At least if you had Financial PoA and the person was scammed you would be able to speak to the bank on their behalf which might be less stressful.

There are other protections set up if someone is scammed – Citizens Advice: Check if you can get your money back after a scam

The solicitor would advise on the detail of the Financial PoA and what areas to include e.g. what your attorney is responsible for – the financial areas they can act on, not the detail of what you have.

It is good to speak to the bank/organisations though if you are coming to a point where you are going to activate powers.

You should also speak with the person who is going to be your Attorney to let them know what accounts you have.

If you don’t have a Welfare PoA set up, it can cause delays in your care. For example, some people stay in the hospital longer than needed because there is no one to make health decisions for them. This means that doctors and nurses are less able to help other patients who need care.

Right now, many people in the NHS Greater Glasgow and Clyde have to stay in the hospital longer because they don’t have a Welfare PoA. This takes up beds that could be used for other patients. It also means ambulances and staff can’t help as many people in the community or in emergency care.

Having a Welfare PoA helps keep things running smoothly and ensures patients get the care they need faster.

If you have Welfare Powers, you may need to make decisions about medical treatment or care homes (if they have lost capacity). But it is a good idea to discuss this with the person in advance if there is a risk of losing capacity.

If your relative thinks they would like to move into a care home, the first step is to contact Social Services who can:

• help you both decide if a care home is the best option, or whether a package of care could allow them to stay in their own home, if they would prefer that
• assess both their care needs and their eligibility for financial help towards care costs (this is important even if they intend to pay for their own care to begin with, in case they need financial help in the future)
• provide help finding a suitable care home – the local council has a responsibility to find a suitable place for anyone they have assessed as needing care in a care home

Example: Perhaps the granter has stated that if their cancer returns, they wish to receive chemotherapy only but not radiotherapy because of the side effects – if it does return and they have lost capacity and radiotherapy is now more advanced without the side effects – can the Attorney ask for this to be considered as well?

Refusals of certain treatment are usually recorded in an Advanced Statement or Advanced Directive. In Scotland these are not legally binding documents, however clinicians and courts would use these to guide decision making if there were any disputes.

If a decision about treatment needs to be made, clinicians will have shared decision making conversations with the Attorney to discuss what might be appropriate. They can use documents like Advanced Statements and Future Care Plans to help try and understand what might be the best plan of action, as well as the information the Attorney may share about the motivations and priorities of the Granter. This might result in certain treatments being given.

This is why it is so important to have lots of conversations with your Attorney about what matters to you and record this in things like a Future Care Plan so everyone can understand what your motivations are.

Death is often a scary topic for people. We have had great conversations with lots of interesting experts about the process and what support is available for anyone at every stage of the journey.

A Day in the Life of…an Anatomical Pathology Technologist

Do you know what an Anatomical Pathology Technologist does? We’ll give you a hint – they work in our hospital mortuaries!

Whilst it may not be the career everyone imagines when they are younger, it can be a hugely rewarding and privileged role to have. This session allowed us to hear from someone with first-hand experience about what it is really like to work in a mortuary.

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DNACPR Policy Update (NHSGGC) 

Conversations about cardiopulmonary resuscitation can be tricky. From the mis-information that circulates, to the strength of emotion it can produce, we need a workforce which understands the intricacy of the policy and how to broach the subject in a sensitive way. 

NHSGGC recently updated their DNACPR policy to clarify who should have these conversations, when they should occur and how to document them. Come along and listen to the team which have been leading this piece of work to tell you about their intentions and also the implication of this update – a must watch for all our staff!

This session is in partnership with the Realistic Medicine Team.

You can watch this on the Grand Rounds Sharepoint site Please note there may be restricted access to this video.

How to Slow Down when Someone Dies

We partnered with Pushing Up The Daises and Caledonia Funeral Aid to a host session which aimed to shine a light on how people can attend to their own wellbeing following the death of a significant person, especially one they may have cared for. During the event we discussed

• ideas for helping you to start your grieving process in a way that best serves you and the people around you,
• the pros and cons of being actively involved yourself with arrangements for burial or cremation and also perhaps the person’s body,
• practical information about the Funeral Support Payment which help people with certain benefits and tax credits to pay for a funeral,
• the laws around death and funerals, and
• why your choices are really important to help your grieving and for your long term well-being.

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Let’s Talk About… Deathcare in the Queer Community

Whether it is planning a funeral, or ensuring that people know your wishes and preferences when it comes to end of life care, having people and tools to help your feel empowered is vital. For members of the Queer community there can be added anxiety about some of these aspects such as what happens with legal paperwork, and how to ensure that the people you want to be involved in care and planning can be. 

This panel discussion discussed some of these questions and provided a space to discuss important topics including how we can create inclusive services which embrace and celebrate people’s identities.

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Let’s Talk About… Hospices

Have you ever visited a hospice? Would it be somewhere you’d be afraid to go?

For many people the word “hospice” is associated with end of life care and death, however the truth is a little different. In this session we heard about all the amazing things hospices do to support people and those who matter to them, recognising that hospices are places of hope and warmth.

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Let’s Talk About… Palliative Care

When you think about palliative care, what is the first thing that comes to mind? “Terminal illness”? “End of life”? “Comfort Care”? Whilst all these things are true, palliative care is so much more than this.

During this panel discussion, people could ask us anything – from “how did you get into this field?” to “what does a “good death” look like?” – the floor was yours!

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Let’s Talk About… Paying for a Funeral

With the average cost of a funeral in Scotland being over £4000*, the financial burden of death and dying can be overwhelming. Caledonia Funeral Aid aim to support people navigating this difficult time by offering advice, as well as practical and emotional support. 

During this session we discussed some of the help that is available such as the Funeral Support Payment as well as thinking about creative ways we can honour and celebrate those who have died. There was also an opportunity to ask questions to our expert.

*Source: SunLife Cost of Dying Report 2024

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Let’s Talk About… Spiritual Considerations at the End of Life

We were delighted to be presenting at NHSGGC Grand Rounds on the topic of spiritual care considerations at the end of life. We are lucky to live in a multi-cultural country, with people coming from all walks of life and bringing their own beliefs and views with them. However sometimes it can be difficult to remember all the different things that we can do to support someone, especially as they approach death.

During this session, colleagues from the spiritual care team explored some of the common, yet simple things we can do as staff to support patients as well as their friends and family, and also highlight some of the resources available to support staff deliver this person-centred care. 

You can watch this on the Grand Rounds Stream Channel. Please note there may be restricted access to this video.

Let’s Talk About… What Happens when Someone is Dying

This is a placeholder tab content. It is important to have the necessary information in the block, but at this stage, it is just a placeholder to help you visualise how the content is displayed. Feel free to edit this with your actual content.Dying is a normal process, but these days the process is often surrounded in mystery. During this sessions we learned more about what actually happens as someone approaches the end of their life and had an opportunity to talk to some experts.

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We have also supported Demystifying Death Week which occurs at the beginning of May each year an aims to shine a light on death, dying and bereavement. You can find some past resources below

Summary Report for the Demystifying Death Week 2022

Demystifying Death Week 2022 – Resource List

Demystifying Death Week 2022 – Carers Resource List

Demystifying Death Week 2023 Programme

Demystifying Death Week 2024 Programme

Demystifying Death Week 2024 Resource List

Demystifing Death Week 2025 Resource List

Grief can be felt at lots of different times and in lots of different ways. We spoke to people from all walks of life about their experience and what helped them process their emotions.

Let’s Talk About… Anticipatory Grief

Whilst some deaths can be sudden and unexpected, most follow a period of illness which could last months or even years. During this time everyone can experience a wealth of emotions including anticipatory grief as we realise that a loss is coming. 

This panel discussion explores anticipatory grief from various points of view including carers of those living with Dementia and parents who have a child with a life-limiting condition.  There was also an opportunity to ask questions to our panel of experts who have backgrounds in various parts of this journey.

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Let’s Talk About… Bereavement in the Workplace

All of us will experience bereavements throughout our lives, so it is very likely that some of these events may happen whilst you are working. Whether it is a sudden loss, or illness which develop over a longer time, trying to juggle work and personal life can be a challenge.

It can also be difficult for colleagues who don’t know what to say or do when someone is dealing with these issues, or returning after the death of someone close.

During this session we explored some of the things we can do to support each other in the workplace including things we can say, places we can signpost to and some of the policies organisations have to support their staff during these incredibly difficult times.

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Let’s Talk About… Bereavement Through Suicide

Stories From 88 Days on a Tandem Around the British Coastline

In January 2022, Xani lost his sister, Alice, to suicide. Since then he and his family have been navigating their own grief journey, supported by a number of different charities including SOBS (Survivors of Bereavement by Suicide).

In the summer of 2023, Xani decided to embark on a mammoth cycling expedition as a tribute to Alice and a way to reach out to others who have been affected by suicide, whilst also raising money for some great organisations. Over 88 days he covered over 3500 miles on a tandem around the British coastline, each day joined by a new person affected by suicide. Together as they pedalled, they shared the story of their experience and the wisdom they had gained. Not only this, he has also managed to raise over £36,000 for both SOBS and PAPYRUS.

From his time on the tandem, Xani has some incredible memories but has also gained a wealth of knowledge about the impact of grief and the different ways people begin to rebuild their lives after tragedy. During this session Xani shared his own story and reflections – from the importance of conversations to meaningful ways to honour those who have died.

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Let’s Talk About… Grief

Grief is natural and something all of us will likely experience at some point. During this session we looked at some of the different models that people have used to describe the grief process and also bust some myths people might have about what is “normal”. 

This session is in partnership with the Beatson Cancer Charity.

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Let’s Talk About… Pet Bereavement

For many people pets are family and so it is only natural to grieve their loss. Wendy Andrew founded the Scottish Pet Bereavement Counselling Service to help others recover from the death of animal companions. 

During this session we talked about everything from the wealth of emotion that accompanies a decision to euthanise a pet, to speaking to children about the death of a pet. We discussed some of the common feelings that people may experience and highlight different places where support is available. There was also an opportunity to ask questions.

This session was delivered in partnership with the Scottish Pet Bereavement Counselling Service.

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Let’s Talk About… Pregnancy and Baby Loss

Everyday people are left with the grief and trauma that often accompanies the loss of a pregnancy or baby shortly after birth. Whilst everyone’s situations are unique, as a society we can do much more to support one another in these difficult times, and that often begin with having a conversation.

During this session we discussed some of the common feelings that people may experience and highlight different places where support is available. There was also an opportunity to ask questions to our panel of experts who have backgrounds in various parts of this bereavement journey.

This session is delivered in partnership with Sands and Antenatal Results and Choices (ARC).

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Seasons of Change

An opportunity for staff to reflect on loss, grief and bereavement

Loss, grief, and bereavement are universal emotions.  Whilst death and dying is a natural part of life, throughout the Covid-19 Pandemic many more people have been touched by experiences which may have triggered feelings associated with loss and change. 

To give staff an opportunity to reflect on both our collective and individual experiences, a new informal online event was created.  The intention was to create a space for staff to reflect and recharge.  There was no active participation necessary, rather staff are encouraged to listen and reflect on the various contemplative pieces (sessions will also have subtitles).   

Staff from across all parts of health and social care were encouraged to attend, including our colleagues in Care Homes, Primary Care and Third Sector.  

You can read our Summary Report for the summer session.

You can also access our Season of Change Summer Session – Resource List

Summer Session:

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Autumn Session:

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We have also support the To Absent Friends Festival, a week-long celebration from 1st-7th November each year to give space to celebrate and reflect on those we miss. Access some resources below.

To Absent Friends 2022 Programme

To Absent Friends 2023 – Resource List

Future Care Planning can cover lots of differnt topics – from Power of Attorney to who would look after the dog if you weren’t able to. Watch our sessions which delve into these areas and give you some tips on how to get started.

Future Care Planning – An Introduction for Staff

Anticipatory Care Planning has benefits for everyone. It empowers people to tell us what really matters; it gives friends and family an opportunity to talk open and honestly; and it helps professionals to work with everyone to create the best care and treatment plans possible. During the session we looked at tools and resources we use across NHSGGC to help promote future planning, and how our systems work together to share information.

ACP is everyone’s business, so make sure you know your role in the conversation.

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Please be aware that the terms “Anticipaotry Care Planning” may be ued in thiss recording. This is the previous term for “Future Care Planning”.

Future Care Planning and Treatment Escalation Plans

How can we help our on-call teams to do the right thing in the middle of the night – when faced with a deteriorating patient that they have never met? Sometimes intervening may be of no benefit or could cause distress but making that judgement can be very difficult. It is possible that there is a plan but accessing it may be a challenge.

In this session we discussed the plans that may be available, how to find them, how to improve them and how to initiate them and have the conversation.

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Please be aware that the terms “Anticipaotry Care Planning” may be ued in thiss recording. This is the previous term for “Future Care Planning”.

Let’s Talk About… Making a POA/Will

The legal parts of future planning can often be confusing, with lots of people not quite sure where to start. This session explored how to get started with Power or Attorney and making a Will, and why both of these things are so important.

We have split the recording into two parts.

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Let’s Talk About… Donating Your Body to Medical Science

What do you want to happen to your body after you die? For most of us, this question makes us think about funeral, burials, cremations. But what about donating your body to help the next generation of students and researchers understand the inner workings of the human body?

During this session we heard from colleagues at the University of Glasgow to learn all about the process that takes place when someone decides to go down this road.

This is in partnership with the University of Glasgow.

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Let’s Talk About… Organ Donation

Did you know that there are around 500 people each year waiting on a transplant, but only about 1% of people die in the rare circumstances where organ and tissue donation may be able to go ahead? This means that every opportunity for donation is very precious!

Hear from the experts working in NHSGGC who are coordinating this life-saving treatment. We bust myths surrounding the process, and hear just what difference an organ transplant can make to someone and the people they love. 

This session was in partnership with the NHSGGC Organ Donation Team.

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Other Bite-sized Training

These recordings are bite sized learning opportunities for staff which focus on a specific topic to provide an overview. They usually last between 30 minutes – 1 hour.

RecordedTopics

• Future Care Plan Clinical Portal Walk Through
• Future Care Planning Introduction
• Rockwood Clinical Frailty Score
• Power of Attorney
• Recoding Future Care Planning on EMIS
• Recording Future Care Planning on CNIS

You can find more information on our training hub pages.

Planning for the Future

When it comes to planning for the future, do you even know where to start? During this informal information session we gave you some ideas of things to think about and tools to help you plan, as well as telling you how this information can be shared with others so that everyone is in the know.

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Plan More, Stress Less

When you or someone you care about becomes ill, life can become very stressful. That is why we think it is so important for people to talk to each other and make plans before this happens.

As part of our Plan More, Stress Less Toolkit, is for anyone interested in getting started with planning ahead. In this session we talk about what paperwork we can complete before a crisis arises, what actually happens when someone goes into hospital and how we can all work together to plan for a safe and timely discharge.

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Hospital Checklist

This checklist will help you think about all the different forms which you can complete just now that would be useful if you were ever in hospital. This includes things like a Future Care Plan and a Power of Attorney.

Click here to download the Preparing For Hospital Checklist

A Plan to Get You Home

This resources lets you and the people who support you, think about what might need to happen in order to get you home from hospital in a safe and timely manner. This includes thinking about who could collect you from hospital and where you might need to live if you need some extra support for a short time or on a more permanent basis.

Click here to download a copy of “A Plan To Get You Home”

What Matters To You Day

“What Matters to You?” Day is an international initiative celebrated on or around June 6 that aims to foster meaningful conversations between patients, caregivers, and healthcare providers.

You can find more information on the initiative and recording of past seminars on our What Matters To You webpages.

What Matters To You Day 2025 – Event Flyer

What Matters to You Day 2025 – The Evaluation

Most people will help to support someone else at some point in their lives. Here are two sessions focusing on how Health and Soical Care staff can help to involve and support unpaid carers in their areas.

If you think you may be a carer and looking for support please visit our Carer Webapges.

Involving and Supporting Unpaid Carers

This session looks at the legal duties of staff working in acute, community and/or primary care. In particular we discuss how staff can encourage carers to recognise their role, how to refer to support services and the legal duty staff have to involve carers in discharge planning. We also mention some of the systems which help us record information about any known carers and share this with other services.

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Involving Unpaid Carers in Care Home Life

When someone moves into a residential or nursing home, it is important that friends and family are still able to be fully involved in their lives. This may include visiting and spending time together either in this new setting, or elsewhere. It is important that friends and family are still supported in their caring role, even if it may look a little different. As everyone adjusts to this “new normal”, there are lots of conversations and pieces of information which can be helpful so that everyone understands what is happening and can share their own views. 

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We have also supported Carers Week and Carers Rights Day. You can find previous resources fro these awareness weeks below.

A Death Cafe is a safe space where people can come together to discuss death, dying and bereavement. It is a free discussion group rather than a grief support or counselling session.

We have hosted Online Cafe in the past and there are still cafes that occur in and raround Glasgow that you may be interested in.

Glasgow Southside Death Cafe

This is an in-person cafe which usually runs the first Thursday of the month 7.30pm-9.00pm at Finns Place (Southside of Glasgow – Langside Church, 167 Ledard Road, Glasgow, G42 9QU). Free refreshments available. For more information and dates visit the Finn’s Place website. Email hello@curiousmortals.co.uk for more details.

Online Death Cafe

The online cafe runs the second Tuesday of the Month, 7.30 – 8.30pm, online via MS teams. You need to register (and make an account the first time) for this café so that you can be sent the joining link. Check out the Curious Mortals website for more details – Past and Future Events — Curious Mortals

The Mitchell Library Death Cafe

These cafes happen at the Mitchell Library in Glasgow on the last Thursday of the month, 5.30pm-7.30pm. For more details and to reserve a place please click this link – The Mitchell Library Death Cafe hosted by Creating Conversations CIC — Glasgow Life

Death Cafe at the Moon Rooms in Newton Mearns

This is a new cafe which takes place on the last Monday of the month at 7.30pm. These are hosted at The Moon Rooms, 81 Broom Road East, Newton Mearns, Uk G77 5LL. There is no need to register, just show up.

Other cafes

Death Cafes are springing up all over the world and there are some that are local. Visit www.deathcafe.com to find your nearest cafe.

In relation to the recent letter from the CMO regarding the name change from “Anticipatory Care Planning” to “Future Care Planning” on 20^th September 2023, we wanted to remind all staff of the current process by which people can share their views and wishes when it comes to future care and treatment within NHSGGC. We also wish to highlight the resources available to support both staff and the public.

Since 2019 we have been storing information about future care planning on the “Anticipatory Care Plan Summary” which sits on Clinical Portal. This document can be edited by any member of staff to record people’s wishes and preferences. It also gives the opportunity to document clinical management plans, record Power of Attorney details as well as DNACPR discussions. A copy of this document is automatically shared with GPs who can update information on the Key Information Summary (KIS). Primary Care staff can read the latest ECS and KIS directions from Scottish Government here. Staff should check both KIS and the ACP Summary to ensure they have all information available.

Within the Board, we believe future care planning is everyone’s responsibility. This is one of the reasons that we have chosen the Clinical Portal system to store future care planning information as it is accessible by Acute, Community and Primary Care as well as Social Work. This means that the majority of health and social care professionals can access and update this information.

We acknowledge that different services will have different conversations based on the roles and remits of the team, however by bringing this information into a central location we can easily share information and help to create person-centred care plans which reflect the wants and needs of people. Therefore our ACP Summary should not be viewed as the responsibility of one individual or service, but rather a dynamic document with many people contributing information.

It is also worth re-iterating that conversations about future care should not just be limited to people at or nearing the end of their life. These conversations can be useful for people at any age and stage of their life and the level of planning required will depend on where someone is in their life journey. We are also encouraging all staff to consider whether someone could benefit from a Frailty Assessment using the Rockwood Clinical Frailty Scale, the results of which can be recorded on the online summary. Early identification and monitoring of frailty is important to help create plans which can slow decline or in some cases reverse frailty. From more information about the Clinical Frailty Scale staff can view a previously recorded session – more details available on the Training Hub.

The Anticipatory Care Programme, which launched in April 2020, is available to support all staff across the Board with information and training. There is an eModule and a variety of recorded training sessions including walkthroughs of Clinical Portal and a Future Care Planning Sway to provide an overview. Anyone can view these sessions and are open to all staff in any role and at any level. For more details please visit the Training Hub.

The ACP Team have also created a wealth of resources for the public including webpages which explain many different aspects of future care planning. They have leaflets which can be printed off with further information (these can be found on the Useful Documents and Resources section of the webpages) and also previous events covering various topics – these are open to view to both staff and the public.

Over the coming months we will be working closely with members of the Scottish Government to ensure that the work that has already taken place in GGC can be shared with other Health Boards and that we continue to align with any national programmes and messaging. We will also continue to work with colleagues in various services and programmes including the Realistic Medicine Team and Unscheduled Care.

We will also begin to change some of the language we use, particularly in public facing areas, to reflect the new term “Future Care Planning”, however during this transition period the phrase “anticipatory care planning” and “ACP” may still be used. The form on Clinical Portal will be updated to “Future Care Plan Summary” in due course.

Full details of the approach to Anticipatory Care Planning/Future Care Planning within NHSGGC can be found in the Guidance/Standard Operating Procedure Document. Please note this will be updated to reflect the new terminology in coming months.

A Future Care Plan is a record of someone wishes. It should be created over time and reflects conversations between a resident, the people that matter to them and the health care professionals that work with them. 

The plan should include:

• a summary of the “thinking ahead” discussions
• a record of the preferred actions, treatments and responses that care providers should make following a decline in health

Some Future Care Plans include information about care at the end of life including where residents would like to be cared for and their wishes about different treatments including resuscitation. All these discussions should be had sensitively and with consideration and should include the people who the resident wishes to be there. 

Some people will not have considered these topics before. It is important that you give them time and space to reflect before having these conversations.

To start with, have a conversation with everyone to explain what Future Care Planning is. You can give them some information to read through and think about it. Let them know you would like to talk more about this in the future.

It is important to involve everyone in these discussions, however if a resident does not have capacity to make these decisions, then it may not be appropriate to give them this information. In these cases we should make every attempt to involve friends, family and carers in order to agree what would be best for the resident and respect their wishes. 

You may feel like you don’t know enough about some topics to give advice to others. For example you might not feel able to answer some questions about DNRCPR, or you might be unsure of the level of support home care can give. If someone asks a question that you don’t know the answer to, be honest about this. Tell them you aren’t sure right now but you will find the information and get back to them. Talk to your colleagues to try and find out the necessary information or visit the Future Care Planning Training Hub to learn more.

There are lots of resources available on on resources page, however here is a lost of resources that might be particularly useful in Care Home settings.

Information Leaflets

Information for Residents – (PDF)

Information for Relatives and Friends – (PDF)

DISCUSS – A Guide For People Thinking About Their Future – PDF

DISCUSS – A Guide For People Thinking About Their Future – PDF (Black & White Version)

DISCUSS – A Guide For Friends, Family and Carers – PDF

DISCUSS – A Guide For Friends, Family and Carers – PDF (Black & White Version)

DISCUSS – A Guide For Staff – PDF

DISCUSS – A Guide For Staff – PDF (Black & White Version)

There are different ways of recording Future Care Plans and each care home may differ. However it’s important to share this information with health and social care partners so that treatment plans reflect people’s wishes.  The easiest way to do this, is to link with the GP who can update the Key Information Summary (KIS). This is an electronic record which NHS24, the Scottish Ambulance Service and hospitals can access.

To help transfer this information quickly and easily, all HSCPs in Greater Glasgow and Clyde use a Future Care Plan Summary to record Future Care Planning decisions. This mirrors the information on the KIS so GPs can if they wish quickly copy information to the KIS. It can be accessed either on Clinical Portal or services can use an interactive PDF.

Some Care Homes have access to Clinical Portal. Unfortunately this is only available currently for HSCP Care Homes. These Homes can fill out the summary directly on there. Clinical Portal will automatically send the Future Care Plan to the GP and they can if they wish transfer the information to the KIS. 

For Homes which do not have direct access to Clinical Portal. they can fill out this interactive PDF and email or post a copy to the GP.

Remember, if any changes are made at the Future Care Plan review, this information needs to be sent to the GP so they can update the KIS.  

Guide to updating Future Care Plans on Clinical Portal (PDF)

Guide to updating Future Care Plans on Clinical Portal (Video)

Guide for GPs Updating eKIS from Future Care Plan Summary (PDF)

People’s wishes and the wishes of those that matter to them, must always be taken into account when deciding on treatment plans. By doing this you will make a plan specific to this individual and based on what is important for them.  

Many residents who live in a care home may choose to remain there if they become unwell. Their main priority might be comfort, and being in their own room, looked after by staff who know them well. However there will be some residents who may benefit from admission to hospital and would want to be transferred. If they do go into hospital it is important to send with them a copy of any previous discussions. If someone has a DNACPR form please send a copy with them.

Anyone can change their mind, and as circumstances change, what is important to people might also change. This is why we think the most important part of the Future Care Planning process is the ongoing conversations with residents and the people that matter to them.  

Final plans do not need to be made but recording the content of these discussions means these plans can be built on. We would expect that Future Care Plans would be reviewed perhaps every 6 months at the time of the resident’s reviews.