Planning for Care Archives

These guidance notes refer to different parts of the ACP Summary on Clinical Portal.

Consent

We do not require explicit consent to share the information contained within the ACP. Therefore the ACP Summary no longer records if someone has given consent to have an ACP.

An ACP is a document brings many pieces of information together into a shareable format. Therefore by engaging in an ACP conversation, the individual (or legal guardian) is agreeing to share this information.

Article 6(1)(e) of the UKGDPR in conjunction with the Intra NHS Scotland Sharing Accord allow the information contained within this document to be shared with Primary Care and other NHS Boards including NHS 24 and Scottish Ambulance, without the need for explicit consent. We are sharing this information for routine patient care as part of our Board’s duty to provide healthcare to our patients. It is best practice for staff to make sure the individual and/or their legal proxy is aware this information will be shared when conducting ACP conversations. If the patient would like further information about how the Board uses their data it can be found in our Privacy Notice here – https://www.nhsggc.org.uk/patients-and-visitors/faqs/data-protection-privacy/#

Recording whether someone would like to share information via ACP

Although we no longer record consent on the ACP Summary, the summary does include a question about whether or not an individual (or their legal guardian) wishes to have an ACP.

By asking this question we hope to enable staff to evidence when a conversation takes place, but the offer of an ACP is declined. We will monitor this data.

If an ACP is refused, staff have the opportunity to record the reason for this. We would ask all staff to complete this in order to provide context to their colleagues who may wish to revisit the conversation at a later date.

Clinical Frailty Score (Rockwood)

We would encourage all staff to consider carrying out a Rockwood Frailty Assessment and select the appropriate score in the ACP Summary.

If a frailty assessment is not applicable please select “0 – Not Applicable”.

Frailty Score Guidance (you can also download an app – Clinical Frailty Scale (CFS) – to help with the assessment – download for apple or android).

Special Notes / What is important to the individual?

Overview of person including family circumstances, accommodation information, health goals, what matters to them, emergency planning information etc. If person is a carer, or has informal carers please state too.

If person lacks capacity ensure this is recorded alongside who has been present during any discussions.

If a person declines an ACP, staff are encouraged to ask permission to record this decision on the ACP Summary so that other services are aware that an ACP has been offered. It is also best practice to indicate whether the person may be willing to revisit these conversations at a later date. Please record this in the appropriate question.

Current Health Problems / Significant Diagnoses

Overview of health issues and diagnoses. Baseline functional and clinical status to help clinician identify deterioration – e.g. baseline O2%, 6-CIT score, level of mobility, current or planned treatments.

It is good practice to indicate if there are any treatments or interventions that the person would not wish. If they have an Advanced Directive this can be indicated.

My preferred place of care

Depending on the person’s own circumstance and health journey, this may include preference about:

long term care (e.g. nursing or residential care)

place of treatment. This could include short or long term treatment.

place of death

This section may also include the current level of care being provided by informal carers and/or any discussions which have occurred regarding on going and future care they may be able to provide.

My views about hospital admission / views about treatments and interventions / family agreement

It is best practice to give as much information as possible regarding views about hospital admission and explore with people what might happen in different scenarios. For example people may be willing to be admitted for a short period for symptom management, however would be unwilling to be admitted if it was likely they would be in hospital for long periods.

For people who are frail, in residential/nursing homes or approaching the end of their lives, it may be useful to discuss the 3 following scenarios:

If you had a sudden illness (such as a stroke or a heart condition), how do you think you would like
to be cared for?
If you had a serious infection that was not improving with treatments we can give in the community like antibiotic tablets or syrup, how do you think you would like to be cared for?
If you were not eating or drinking because you were now very unwell, how do you think you would like to be cared for?

Current Events

Monthly Death Cafes (Virtual)

Let’s break the taboo, and talk about Death! This event is an informal space to talk with others about something which affects us all…so boil the kettle, raid the biscuit tin and come and join the conversation!

Please note that this is a discussion group rather than a grief support or counselling session.

These events are open to staff and members of the public.

Currently these events happen on MS Teams so places are limited. However, if you are a curious about what a Death Café might be like, we’d encourage you to come along and say hello! Whether you’d like to dip your toe in the water, or keen to become a regular, you can register for any of our cafes by selecting a date below:

Monday 22^nd August 2022 7-8pm

Monday 19^th September 2022 7-8pm

Monday 24^th October 2022 7-8pm

Monday 21^st November 2022 7-8pm

Monday 19^th December 2022 7-8pm

Lunch & Learn Sessions

Lunch & Learn Sessions are informal events for staff to highlight new ways of working and give people an opportunity to ask questions. They usually last around 30 minutes. Check out our current themes and dates of sessions below.

Lunch & Learn Session: New ACP Summary

In June, the ACP Summary was updated. Come along to hear about some of the key changes that have been made as well as how to create and update the document. These sessions are open to all staff across health and social care.

You can register for any of these session by clicking on your preferred date.

Dates of Sessions:

Monday 22^nd August 2022 – 1.00-1.30pm

Thursday 25^th August 2022 – 12.30-1.00pm

Thursday 1^st August 2022 – 1.00-1.30pm

Lunch & Learn Session: Recording ACP Journeys via EMIS

Come along to learn which codes should be used as well as a demonstration of how coding works on the EMIS system. These sessions are open to all staff across health and social care who use the EMIS platform.

You can register for any of these session by clicking on your preferred date.

Dates of Sessions:

Tuesday 23^rd August 2022 – 12.30-1.00pm

Friday 26^th August 2022 – 1.00-1.30pm

Monday 29^th August 2022 – 12.30-1.00pm

You can read about past events below. We have also recorded some of our events so that you can watch them in your own time – the videos are available under each event description.

Past Events

Demystifying Death Week 2022

2nd – 6th May 2022

Demystifying death week is about shining a light on death, dying and bereavement in Scotland. Events throughout the week will give people knowledge, skills and opportunities to plan and support each other through death, dying, loss and care.

This year NHSGGC ran 13 events across the week. Some events were recorded and you can watch them below.

You can read our Summary Report for the week.

Additional Resources:

Demystifying Death Week 2022 – Resource List

Demystifying Death Week 2022 – Carers Resource List

Demystifying Death Week 2022 Events

Taking Care of Yourself When Looking After Someone

Supporting other people can take its toll, and whilst it may be the last thing on our minds, taking time for ourselves is really important. Come along for an informal chat about some ways to help recharge and promote self-care.

This session was not recorded.

Death Cafe

Let’s break the taboo, and talk about Death! This event is an informal space to talk with others about something which affects us all…so boil the kettle, raid the biscuit tin and come and join the conversation!

Please note that this is a discussion group rather than a grief support or counselling session.

This session was not recorded.

Having Conversations That Matter

This is an experiential workshop to give participants an easy way to start thinking about what’s important to them and those around them. This event is open to any member of staff working in Health and Social Care across the Greater Glasgow and Clyde Health Board Area.

This session was not recorded.

Anticipatory 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 will be looking 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.

You can watch the recording here:

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 will give 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.

You can watch the recording here:

Preparing for Hospital – What You Need to Know

No one wants to go into hospital, but sometimes it is unavoidable. However there are some simple things we can do now, to try and make the experience less stressful for everyone.

Come along to learn about making “grab bags”, what paperwork to bring along and what the discharge process might look like. This event might be particularly useful for anyone supporting someone else and worried about what the future might look like.

You can watch the recording here:

What is 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. It is about improving the quality of life of anyone facing a life-limiting condition and can be beneficial at lots points during someone’s health journey. During this session, we will be busting some myths when it comes to Palliative Care and also exploring the support that the NHSGGC Specialist Palliative Care Team can provide both colleagues and patients.

Recording will be available shortly.

Power of Attorney / Making a Will

The legal parts of future planning can often be confusing, with lots of people not quite sure where to start. This session will explore how to get started with Power or Attorney and making a Will, and why both of these things are so important. There will also be an opportunity to put any questions you have to an expert.

You can watch the part of the session about Power of Attorney here:

You can watch the part of the session about Wills here:

Anticipatory Care Planning Communication Skills Training

This is part of our usual training programme. The session helps staff reflect on the best way to incorporate ACP conversations into their everyday practice.

This session was not recorded.

For future dates please visit our ACP Training Hub

Anticipatory 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. We will discuss the plans that may be available, how to find them, how to improve them and how to initiate them and have the conversation. Please note, this is a recording on a session which took place as part of NHSGGC’s Realistic Medicine Week in March 2022.

Recording will be available shortly.

What Happens When Someone is Dying

Dying is a normal process, but these days the process is often surrounded in mystery. Come along to learn more about what actually happens as someone approaches the end of their life and have an opportunity to talk to some experts.

This session was not recorded.

Seasons of Change – Spring Session 2022

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, during the past two years it is likely that 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.

Sessions ran on MS Teams everyday during lunchtime of the week 16th-20th May 2022.

You can read our Summary Report for the session.

You can now watch the session in your own time.

Additional Resources:

Seasons of Change – Spring 2022 – Resource List

Carers Week 2022

Carers Week is an annual campaign to raise awareness of caring, highlight the challenges unpaid carers face and recognise the contribution they make to families and communities throughout the UK. It also helps people who don’t think of themselves as having caring responsibilities to identify as carers and access much-needed support.

The campaign is brought to life by thousands of individuals and organisations who come together to provide support for carers, run activities, highlight the vital role carers play in our communities and draw attention to just how important caring is.

This year NHSGGC hosted 5 events as part of Carers Week 2022. We will also be highlighting how staff can help support carers and work with them as equal partners in care. Please follow @NHSGGCCarers on Twitter for all the latest updates.

You can read our Summary Report for the week.

Additional Resources:

Carers Week 2022 – Resource List

Taking Care of Yourself When Looking After Someone

Supporting other people can take its toll, and whilst it may be the last thing on our minds, taking time for ourselves is really important. Come along for an informal chat about some ways to help recharge and promote self-care.

This session was not recorded.