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Planning for Care
Across NHSGGC we aim to deliver person-centred care. To do this we need to work with everyone – the person, those who matter to them and the other health care professionals involved in their care.
If the person you work with is supported by friends, family or neighbours in a caring capacity you should refer them to carer support services.
Updates to the Future Care Plan Document (June 2025)
Since 2019 we have been storing information about future care planning on Clinical Portal. The 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 Future Care Plan Summary to ensure they have all information available.
In 2023, we started to use the phrase “Future Care Planning” instead of “Anticipatory Care Planning”. This helped us to emphasis how broad these conversations can be, and all the different topics we can talk about.
As of June 2025, our digital documentation on Clinical Portal now reflects this language. There have also been a few other changes to the documentation we wanted to highlight.
The document is now called the ‘Future Care Plan’ Summary, not the “Anticipatory Care Plan” Summary.
You will still find the document stored under “Care Plans” in the category view, or “Acute Specialities GGC” in the speciality view. The phrase “Anticipatory Care Plan” may still appear in places due to legacy systems, but this should not cause alarm. When creating a new plan you should still go to the “Forms & Pathways Tab” and then click “Add/update Future Care Plan” on the left hand side.
Remember if an old version of the plan exists (i.e. it is still called the Anticipatory Care Plan at the top of the form) please “close” the form, so that the new format can be activated at the next update. You can note that there is an older version on file within the “Special Notes” section of the new document. You don’t need to copy all previous information into the new form, staff should use their own discretion to transfer relevant information.
New options for the Job Role, Area and Trigger drop downs
Care Home and Hospice staff should now select this as their “Job Role” and select the appropriate HSCP they are based in as their “Directorate”. This will help us identify local engagement more easily.
Additional “trigger” options have also been added to the digital document including “Hospital At Home” and “Assessed by HomeFirst Response service” – please use these when necessary.
Please note the PDF version of the form does not include these additional triggers, however it can be noted under “Other”.
Confirmation of Power of Attorney Documentation
Staff should ask to see a copy of any Power of Attorney documentation and record when this happened. Some people may be confused between different legal paperwork (Wills, Types of Power of Attorney, Guardianship Orders, Advance Directives etc) so this helps ensure that everyone knows who has the authority to make decisions for someone.
New question on Treatment Escalation Plans
Treatment Escalation Plans (TEPs) are becoming more common in our Acute sites. If someone has a TEP completed while in hospital this should now be recorded in the Future Care Plan, stating the date, which hospital they were in and the level of escalation suggested.
Recording this information will help us monitor TEP uptake as well as alert community staff to some of the conversations that may have occurred already and which they can build on as they continue to have Future Care Planning discussions.
The PDF version of the Summary has also been updated to reflect the new layout and data that is captured on Clinical Portal.
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 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 and other staff training visit the Training Hub.
There is a wealth of resources for the public including webpages which explain many different aspects of future care planning. There are 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 recordings of events covering various topics.
Full details of the approach to 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.
You can contact ggc.HomeFirst@nhs.scot with any questions or for further information.
Information for Current Staff
Information for New Staff and Students
If you are new to NHSGGC then we would recommend that you take a look at our training hub. This will help you understand what happens in our Health Board and what role you can play. There may also be specific training for your specific role or area. Check with your line manager or practice development team.
Information for Care Home Staff
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The term “Anticipatory Care Panning (ACP)” has become “Future Care Planning” to reflect the broad range of topics which can and should be discussed as part of these conversations. All resources have been updated to reflect this, however the main content of resources and training remains the same.
There are different types of online training available to help staff increase their skills and knowledge. Anyone can view our recorded training sessions and access our topic specific Microsoft Sways that are aimed at giving staff a strong foundation from which to start conversations.
There is currently no live training sessions as the dedicated Future Care Planning support is no longer available. If you are a member of staff who wishes to deliver training for their team then you can access training packs and resources on the Future Care Planning Sharepoint site (this is only available to NHSGGC staff).
Introduction to Future Care Planning E-module
The aim of this module is to provide staff with a general understanding of the Future Care Planning process.
Some of this information may be familiar to you, particularly if you are already having Future Care Planning conversations with people.
The E-module currently sits on the Microsoft SWAY platform.
You can access the module here.
You can also complete the module via LearnPro if you have access. Search for GGC028: Future Care Planning.
Once you have completed the module you can complete the assessment, after which you will be sent a certificate to keep in your records.
Bite Sized Learning
Future Care Planning encompasses many different topics and there are systems that staff need to access to record this information. A series of bite-sized learning opportunities have been developed providing online recorded sessions which staff can view.
There are also training packs and resources that have been developed for staff who wish to upskill their teams and colleagues by running face to face training. These resources can be accessed via the SharePoint Site (please note this is only accessible to NHSGGC staff).
You can also view previously recorded sessions covering a wide range of event topics we have covered in the last few years, these are available to view in our “Past Events” section on our Events Pages.
Future Care Planning Overview
Everyone has a role to play in Future Care Planning, helping to have record these conversations as well as access the information when necessary. This is an interactive Microsoft Sway which will provide an overview of what Future Care Planning is, who it is for and why it is important to plan for future health and care.
This Sway covers:
- Identifying triggers for Future Care Planning Conversations.
- How to plan for Future Care Planning Conversations and ensure you are prepared.
- Future Care Planning Conversation – suggested topics to cover.
- Identify barriers / challenges and ways to overcome these.
- How to use systems to record Future Care Planning Conversations.
- Where to access further resources for yourself and others.
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Future Care Planning Walkthrough on Clinical Portal
Future Care Planning is key to providing good person-centred care, and sharing this information between services ensures that the right decisions can be made. During this recorded session we will show you how to access the Future Care Plan on Clinical Portal, take you through each section and suggest information that can be included.
Rockwood Clinical Frailty Scale Overview
Identifying people as ‘frail’ can be misleading and often creates a picture of someone who has not aged well. People living within the ‘spectrum of frailty’ can be supported with timely and targeted interventions and if we screen people early enough, we can sustain and even reverse someone’s level of frailty.
We are encouraging all health and social care practitioners to screen for frailty by using the Rockwood Clinical Frailty Scale (CFS) and support people to have conversations about their future care.
During this recorded session we will introduce the CFS, examples of people at different points on the scale and discuss how the CFS can be recorded as part of the Future Care Plan.
We also have a Microsoft Sway you can access to provide context to the recorded session.
Power of Attorney Overview
The legal parts of future planning can often be confusing, with lots of people not quite sure where to start. This session explores how to get started with Power or Attorney and why this is so important.
We also have a Microsoft Sway you can access to provide context to the recorded session.
Recording Future Care Planning Journeys (EMIS and CNIS)
Future Care Planning is key to providing good person centred care. Many services are now having and recording Future Care Planning conversations as part of their core ways of working.
In order to help us monitor uptake and improvement, services are also asked to track the Future Care Planning journey of individuals. One easy way to manage this is via Future Care Planning Codes on either the EMIS or CNIS platform for each patient.
For staff using CNIS, it is important to correctly document people’s Future Care Planning journey. This session demonstrates how to update the system and what codes to use.
We also have a Microsoft Sway you can access to provide context to the recorded session.
For staff using EMIS, it is important to correctly document people’s Future Care Planning journey. This session demonstrates how to update the system and what codes to use.
We also have a Microsoft Sway you can access to provide context to the recorded session.
Training and Information for Care Home Staff
All our information and resources are available to all Care Home staff. This includes access to the Future Care Planning e-module and all our recorded sessions and Sways. We also have a specific page on our website dedicated to Information for Care Homes.
Plan More, Stress Less
Plan More, Stress Less
As part of our Plan More, Stress Less toolkit, you can view a recorded session which covers all you need to know about getting yourself, and those you support prepared for any unexpected event including hospital admissions.
Topics covered in the session include:
- Helpful paperwork
- What to bring to hospital
- What conversations we may have whilst in hospital
- Planning for a successful discharge from hospital
- Post-discharge support
Alongside this session we have created two resources which anyone can use to help them plan for any future hospital admission. This could be a planned admission, for example if someone is going to hospital for an operation or to have some tests. However these resources can also be useful if someone needs to go to hospital in an emergency.
Preparing for 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.
A Plan to Get You Home
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. 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.
Realistic Conversations (Communication Skills Training)
During these online webinars participants observe an interactive demonstration of a clinical conversation. Participants identify helpful communication behaviours and contribute suggestions to direct the conversation via the chat function.
Sessions run throughout the year and cover various themes such as Future Care Planning (ACP), Treatment Escalation Planning (TEP) and shared decision making conversations
For more information including future dates and registration links please visit the NHSGGC pages of EC4H.
Further Training and Skills Practice
Communication is a skill which needs practice. There are lots of different courses and resources available to help you think about how to communicate with other. Here are some of our recommendations.
Face to Face Training Courses*
Sage & Thyme Communication Training
The MAP of Behaviour Change (Behaviour change for health)
*Please note that some of these course may not currently be running or may have moved to a virtual platform.
Online Modules
We have created our own online module which gives you a general overview of Future Care Planning (also known as Anticipatory Care Planning).
There are 2 Learnpro Modules we would suggest. Please note you will need to have a Learnpro account to access these.
GGC 028: Future Care Planning
GGC 053: Palliative End of Life Care
The NHSGGC Primary Care Palliative Care Team run a variety of online and face to face training, including sessions on Future Care Planning, Communication Skills and DNACPR.
Macmillan Learnzone Resources
You can download their Education and Training Opportunities Prospectus for Health and Social Care Professionals.
Please note, you will be required to sign up to the Learning Hub, this is where you can book onto virtual classrooms, access e-learning and find resources. Courses include Communication Skills, Palliative Care, Personalised Care and Support Planning and Primary, Community and Social Care.
NHS Education for Scotland (NES) Resources
Turas Learn is a website for Health and Social Care staff that hosts a wide range of learning materials including eLearning modules and courses.
There are a wide range of educational resources which provide guidance and support to enhance your ongoing professional development.
You must be logged into your Turas Account to view and access eLearning modules Sign In. If you do not have a Turas account you can create one
Other Resources
Difficult Conversations – Talking About Death and Dying (Video)
Delivering Bad News Video – Irish Hospice Foundation
End of Life Aid Skills for Everyone (EASE)
EASE four-week course which is delivered either in person or online via MS Teams and the learning platform Moodle. The course is designed to enable people to be more comfortable and confident supporting family and community members with issues they face during dying, death and bereavement. The course has been developed by the Scottish Partnership for Palliative Care.
This is not a clinical skills course and participants do not need to have any prior knowledge or experience of death, dying and bereavement.
Over 5 weeks we will explore different topics including;
- Getting comfortable talking about death and dying
- What death looks like in 21st Century Scotland
- The role of Health and Social Care
- Serious illness and frailty
- Future planning
- Medicines and treatments at the end of life
- Active Listening
- Bereavement and grief
- Caring for the carer
You must be able to attend all sessions and commit to completing the online activities prior to each discussion workshop.
To find out more about the EASE course, including if there are local course happening visit End of Life Aid Skills for Everyone (EASE) | Good Life, Good Death, Good Grief.
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A Future Care Planning Champion can be any professional who has an interest in helping create a culture of open and honest conversations about future care planning.
What is a Future Care Planning Champion responsible for?
The Future Care Planning Champion role is an opportunity to further develop your knowledge and skills. You will be able to help create a person-centred culture by:
- Helping colleagues understand the importance of Future Care Planning
- Signpost colleagues to useful resources
- Offer feedback to your line manager/service leads on behalf of your colleagues
- Produce or adapt existing resources to support your colleagues
What is a Future Care Planning Champion not responsible for?
If you are a Future Care Planning Champion this does not mean that you are the only member of your team who should be completing Future Care Plans. Helping people make informed choices and feel in control of their health should be everyone’s business.
The Future Care Planning Champion is not a registered role and is not mandatory for staff.
Why become a Future Care Planning Champion?
By becoming a Future Care Planning champion you will be helping NHSGGC deliver excellent person-centred care, however it is also a great opportunity for your personal development.
Champions will be able to develop their knowledge and skills through:
- Access to Future Care Planning training resources through the Future Care Planning SharePoint Site
- Representing colleagues in feedback forums
- Helping shape training for colleagues across NHSGGC
- Opportunities to pursue quality improvement projects within teams regarding Future Care Plans
- Support from your line manager/team leads
- Support from fellow colleagues who have an interest in Future Care Planning
These development opportunities link to the following KSF categories:
C1 – Communication
C2 – Personal and People Development
C4 – Service Improvement
Q5 – Quality
If you would like to find out more you can download this Role Description.
To become a Future Care Planning Champion please talk this through with your Line Manager.
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What tools can we use?
As health care professional we will find some planning tools more useful than other, however we should still encourage everyone to think about all the different tools.
These include:
- Future Care Plans
- Power of Attorney
- Emergency Care Plans
- Carer Support Plans
- Wills
We need to use these records as a foundation for all clinical decisions that we make. We should always try and involve the person and those that matter to them as much as possible when making treatment plans.
Future Care Planning (also known as ACP)
A Future Care Plan is one of the most important documents that we can help people with. It is a record of what matters to them and information that will be useful in making any decisions. If someone loses capacity, or we cannot discuss the situation with those that matter to them, we can use the record of discussion to help us make decisions.
Power of Attorney (POA)
If someone has a welfare Power of Attorney, and they have lost capacity, we must include the attorney in the discussions. Even if someone still has capacity it is a good idea to try and involve the attorney where possible.
Emergency Plans
If someone is admitted to hospital, or is likely to be admitted we should enquire about emergency care plans and where possible help to implement them. These emergency care plans will often identify things which people may be concerned or stressed about e.g. a family member or pet. By helping to quickly resolve issues we can make people feel less anxious.
Future Care Plans – Information for Professionals
What is a Future Care Plan?
Future Care Planning helps people to think ahead and understand their health. It helps people know how to use services better and it helps them make choices about their future care.
This is a process and should involve ongoing conversations between a person, the people that matter to them and the health care professionals involved in their care.
The decisions made during these conversations are recorded in a Future Care Plan.
The plan should include:
- a summary of discussions
- a record of the preferred actions, treatments and responses that care providers should make following a decline in health
Future Care Plans will often include information about care at the end of life. This includes where people would prefer to be cared for and their wishes about different treatments, including resuscitation. All these discussions should be had sensitively and with consideration.
How do I use a Future Care Plan to inform Care?
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.
A Future Care Plan can help us plan for where treatment should be delivered and this in turn may lead to discussions about the level of treatment which can be provided in these locations. It is important that we come to an understanding with people regarding their health goals so that we can make realistic plans.
What is the difference between a Treatment Escalation Plan (TEP) and an Future Care Plan (also known as an ACP)?
What is a TEP?
A Treatment Escalation Plan (TEP) is a document which is completed during a hospital stay (usually on admission or following a change in circumstance). This document records decisions related to escalation of treatment, and the investigations and interventions that are deemed appropriate in the event of deterioration. The aim of this process is to give clear instruction so as to avoid any unnecessary or non-beneficial interventions at the end of life.
A TEP is only valid until a the person is discharged or has died. Upon each new admission a new TEP must be completed.
What is a Future Care Plan?
A Future Care Plan (also known as an ACP) documents the goals and preferences of the person, which may include decisions about end of life care and treatment. This helps everyone make a unique treatment plan which reflects the person’s wishes and values. A Future Care Plan is a record of ongoing discussions which may evolve as circumstances change. A Future Care Plan may be used in acute or community settings. Anyone may have a Future Care Plan and the document is valid at all times.
A Future Care Plan may inform what information is recorded in a TEP (review the Portal Future Care Plan on admission). Similarly any new discussions or decisions that are made when making the TEP should be recorded on the Portal Future Care Plan so that colleagues out-with acute setting have all the relevant information they require.
More information on TEPs is available on the NHSGGC Right Decision’s webpages.
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We need to record Future Care Planning discussions and the decisions made so that everyone has an understanding of what matters to each individual and how we can best support them and those that matter to them.
Recording Relevant Information
Most services will have their own paperwork which they use to document important conversations and decisions. For instance, social work might be aware of any home care services which are used; physiotherapy may have had a conversation about what is a realistic mobility goal; the district nurse may have spoken to the person about where they would prefer to receive end of life care. As health care professionals it is your responsibility to try and ensure your colleagues in other departments know this information.
Using the Future Care Plan Summary is a good way to share this information (also known as an ACP Summary).
You do not need to complete every part of the document. If we all take responsibility for inputting the information we have gathered in our own assessments, then this will help ensure the final Future Care Plan has all the information needed.
Which documents should I use?
Key information will be recorded in lots of different places. Your department might have their own records and documentation that they use.
The people you work with may also be using different documents to record their thoughts about Future Care Planning. They might have a “My Anticipatory Care Plan” or a ReSPECT form. There are other planning tools they might have used as well.
We can still use all these different documents. However the most important thing is key information from all of these places is recorded in the Future Care Plan Summary which is available on Clinical Portal. It is your responsibility to help summarise this information and add it to the shared document.
This will ensure that your colleagues in different departments and services can access the information they need, and will also allow you to see information that other professionals have gathered.
The Future Care Plan Summary is held on Clinical Portal. For more information see “Sharing Future Care Planning Information”.
Sharing Future Care Planning Information
It is really important that this information is shared with all health and social care partners so that any treatment plans reflect people’s wishes. The easiest way to ensure that information can be accessed by everyone who needs it is through 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 an 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 (it will sit under “Care Plans” in the Clinical Documents), or services can use an interactive PDF.
If you have access to Clinical Portal you 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.
If you do not have access to Clinical Portal you can fill out this interactive PDF and email or post a copy to the GP.
Remember, if any changes are made to the Future Care Plan 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)
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We need to have good conversations where we can talk openly and honestly about people’s wishes and their health goals. We also need to make sure they have all the information they need to make informed choices and understand the benefits and limitations of different treatments.
Getting Started
Good communication is the key to success. 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.
It may be useful to have an introductory conversation with people and those that matter to them, explaining that you would like to have further conversations soon. You can signpost them to the information in these pages.
Raising Important Topics
These discussions are really important; however we understand that some staff members might not always feel comfortable having them. Try not to overcomplicate the matter – we can often start conversations with a simple question like ‘what matters to you?’ or ‘how would you feel if you have to go to hospital?’ and we often find that people are keen to discuss this, as are those who matter to them.
What should we DISCUSS?
We have created some resources to help you think about the different topics you could talk about as part of an Future Care Planning Conversation. They use the “DISCUSS” framework.
You may also 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.
Encourage Questions – It’s Okay To Ask Campaign/BRAN Questions
During these conversations, it is important that everyone is given a chance to express their views so that we can make shared decisions. It is also important for professionals to check in with people to make sure that they understand what is being discussed and are happy with the plan.
The BRAN Questions can be a useful way to check that everyone has the information they need to make an informed choice about different treatments or plans. These are four questions that ask about the benefits, risks and alternatives of treatment, as well as what would happen if we did nothing.
B – What are the Benefits of this test or procedure?
R – What are the Risks of this test or procedure?
A – Are there any Alternatives?
N – What if I do Nothing?
BRAN also applies to clinicians! We should also ask ourselves:
B – Will this patient really Benefit from this test / procedure / hospitalisation?
R – Am I exposing this patient to Risks?
A – What Alternative options have we discussed?
N – if I were this patient, would I consider doing Nothing at this stage?
Visit the NHS Inform: It’s Ok to Ask website for more information.
Training and Skills Practice
Communication is a skill which needs practice. There are lots of different courses and resources available to help you think about how to communicate with other. Here are some of our recommendations:
Face to Face Training Courses*
Sage & Thyme Communication Training
*Please note that some of these course may not currently be running or may have moved to a virtual platform.
Online Modules
We have created our own online e-learning module which gives you a general overview of Future Care Planning.
There are 2 Learnpro Modules we would suggest. Please note you will need to have a Learnpro account to access these.
GGC 028: Future Care Planning
GGC 053: Palliative End of Life Care
The NHSGGC Primary Care Palliative Care Team run a variety of online and face to face training, including sessions on Future Care Planning, communication skills and DNACPR.
Macmillan Learnzone Resources
You can download their Education and Training Opportunities Prospectus for Health and Social Care Professionals.
Please note, you will be required to sign up to the Learning Hub, this is where you can book onto virtual classrooms, access e-learning and find resources. Courses include Communication Skills, Palliative Care, Personalised Care and Support Planning and Primary, Community and Social Care
NHS Education for Scotland (NES) Resources
Turas Learn is a website for Health and Social Care staff that hosts a wide range of learning materials including eLearning modules and courses.
There are a wide range of educational resources which provide guidance and support to enhance your ongoing professional development.
You must be logged into your Turas Account to view and access eLearning modules Sign In. If you do not have a Turas account you can create one
Other Resources
EC4H (Effective Communication For Healthcare)
Difficult Conversations – Talking About Death and Dying (Video)
Delivering Bad News Video – Irish Hospice Foundation
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Why should you plan your care?
Planning your care allows you to be in control and lets others know what is important to you. This means we can all work together to make treatment plans that are unique to you and respect your wishes.
These conversations ask some big questions and sometimes it can be difficult to know where to begin. Here are some tips to get you started.
Conversation Tips
Don’t Rush
Take some time to think about what matters to you and who matters to you.
Do Some Research
Everyone is unique and has their own ideas about what they would like. However there might be things you’ve never considered like where you would prefer to receive treatment, or what treatments you would or would not want. Talk to people involved in your care and ask them to explain all the options that are available so that you can make an informed choice.
Speak To The People Who Matter To You
Let them know that you think this is really important and you want to have this conversation. Often we don’t talk about these topics because we think it will be upsetting for everyone involved, but these conversations give people the opportunity to learn more about each other which many people appreciate. It is also reassuring for people to know what your wishes are so that if they need to, they can make decisions that match these.
Make Notes
You don’t need to make a formal plan right away but it can be helpful to take some notes while you think about these topics. You can then use these notes when it comes to filling out the proper documentation.
Remember – Plans Are Not Set In Stone
Everyone has the right to change their mind. Situations can change and what matters to you might change to reflect what is going on in your life. It is important to revisit these conversations with the people that matter to you and any health care staff involved in your care so that everyone is aware of any changes in your wishes. These can then be updated in the documentation.
It’s Okay To Ask Questions!
When plans are being made, it is important that everyone is given a chance to express their views so that we can make shared decisions and find the best option for you.
The BRAN Questions can be a useful way to check that you have all the information you need to make an informed choice about different treatments or plans. These are four questions that ask about the benefits, risks and alternatives of treatment, as well as what would happen if we did nothing.
B – What are the Benefits of this test or procedure?
R – What are the Risks of this test or procedure?
A – Are there any Alternatives?
N – What if I do Nothing?
When you are talking to any professional about different options, don’t be afraid to ask these questions – we are more than happy to talk about all of these with you!
Visit the NHS Inform: It’s Ok to Ask website for more information.
Next Steps
Do you support someone living in a Care Home?
We are currently trying to encourage Care Homes residents and their friends and family to have conversations about what matters to them. This includes thinking about what might happen in the future. Please visit our information page of Care Homes for more information
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Getting Started
There are lots of different things people can use to help let others know what they want to happen.
Some of these are legal documents so it would be useful to have a lawyer or solicitor to help complete them. There may be a cost involved, however in some cases, you may be able to apply for funding to cover all or part of the cost. If you want to find out more about costs you can visit the Citizen’s Advice Scotland website.
Even if a document is not legally binding it is can still help others understand what is important to you so that any decisions that need to be made can reflect this.
Here are some of the documents and processes that people can use to help plan for their futures.
Topics to Think About
Future Care Plans
What is a Future Care Plan?
Why should I have a Future Care Plan?
What goes in a Future Care Plan?
How can I get a Future Care Plan?
Everyone has the right to a Future Care Plan.
Future Care Plans are not legally binding and there is not one way to record these decisions. The most important part of the Future Care Planning process is having the conversations; however it makes things a lot easier if any decisions made in these conversations are written down. This means that everyone can refer back to the document if they have to make decisions in future.
There are lots of different documents that can help you think about what is important and give you space to record the decisions you make. Here are some examples:
Documents to Help You Plan
My Anticipatory Care Plan
My Anticipatory Care Plan – this booklet was made by Health Improvement Scotland. It asks different questions and helps you make a plan which has lots of detail.
You can download a PDF of the booklet, or find out more information about Health Improvement Scotland.
You can either print off the booklet or you can type your answers straight onto the PDF (just click on each box). If you type straight into the PDF then you can save it and even email it to the people that matter to you. This means that everyone knows the important information and can easily access it.
You can also change your answers at any time – just remember to send the new copy to everyone so that they have the most up to date copy.
There is also an app you can download which helps you record the most important parts of the booklet. If you have this then you will always have a copy of your plan close by.
If you need the booklet in a different language then please email contactpublicinvolvement.hus@nhs.net or call 0141 225 6999.
My Thinking Ahead and Making Plans Booklet
My Thinking Ahead and Making Plans booklet – this is a shorter booklet but still helps you to think about lots of important decisions.
This booklet is also available in Urdu and Punjabi. If you need the booklet in a different language then please email ggc.HomeFirst@nhs.scot
These are just some suggestions and there will be other versions available. It is important that you can find tools that you like and you feel are useful and easy to use. Do some research and find the one that is right for you and the people that matter to you.
How can I share my Future Care Plan with others?
Start off by thinking about what matters to you and writing these thoughts down. Above you will find some example of tools which can help.
Now you need to share these with everyone who needs to know about your wishes.
If you already have health care teams working with you, they may have their own documents which they use to record summaries of these decisions. Speak to them and let them know you would like to talk about Future Care Planning. You can share any plans you have created with them and they can record the key information on their systems.
Even if you don’t have a health care team working with you, we still think it would be a good idea to write down your wishes. You can share these plans with anyone you would like to know this information. For example we would encourage you to speak to your GP to let them know any decisions you have made and ask them to update your file to reflect your wishes.
What is the difference between making a Future Care Plan and a discussion about CPR?
A Future Care Plan contains lots of different information. It will record what matters to you – who is important to you, where you would prefer to receive treatment if possible, and what treatment you would like or treatment you would not like. This information helps us to work with you to make any treatment plans, at any stage of your life.
It may also contain information about end of life care. This is an important part of the document as it will help us work with you to make appropriate treatment plans at the end of your life. We will talk to you about where you would prefer to be treated at the end of your life, who you would like to be with you and your thoughts about what treatments you would like or not like.
We may also talk about what you prefer to happen if your heart stops. Sometimes it may be appropriate to try CPR to try and restart your heart. However this process has its own risks and does not work very often. We might talk to you about completing a DNACPR form – this stands for “do not attempt cardiopulmonary resuscitation”. If a DNACPR is in place this means that if your heart stops, health care professionals will not attempt to restart it. It does not mean that you would not receive other treatment or that we cannot provide care to make you as comfortable as possible.
A CPR conversation is a very small part of the Future Care Planning process, however it gives you and the people that matter to you a chance to talk about your wishes and ask the health care staff involved in your care any questions you might have. It also makes sure that everyone is aware of decisions that have been made.
Scottish Government have also produced a leaflet to tell you more about CPR.
How much does a Future Care Plan cost?
Future Care Plans do not cost any money. All you need to do is have a conversation with those that matter to you and make a record of your wishes. You should then speak to any health care professional involved in your care so they can make sure the key information is store in their records and shared with colleagues.
Planning For Unexpected Events
Unexpected things can happen every day. Having a plan for what to do in an emergency situation can help reduce stress and anxiety.
What do I need to think about?
These plans usually focus on what would happen in an emergency situation e.g. if someone was unexpectedly admitted to hospital. Some things that people might want to think about:
- If you care for someone, who will provide this care when you are unavailable? Will you require extra support from Social Work?
- If you have children is there someone who can stay with them?
- If you have any pets is there someone who can look after them?
- Does someone have a spare key to get into your house if you need something from there?
Why should I think about these things?
Having a plan in place can reduce the stress for everyone – the person, their friends, family members and carers. It means that everyone knows what is expected of them, and they can ask for help if they need it.
How do I make a plan?
Just like a Future Care Plan, planning for unexpected events begins with a conversation. You should talk to the people that matter to you and those you are responsible for. You should then make a record of these decisions and give everyone involved a copy.
This plan is not legally binding and can be updated at any time to reflect changes in your thinking or circumstances.
A Tool to Help You Plan
Carers Link East Dunbartonshire have created a great tool to help you make an plan.
Once completed they will email you a copy of the document and provide a link so that you can update it at any time. You can print off a copy or forward it to any of your emergency contacts so that everyone has the information they need.
Not sure what goes in an plan? We have made an example plan for you to look at.
How much does it cost to make a plan?
Making a plan does not cost anything. All you need to do is talk with the people that matter to you and make an agreement as to what should happen if something unexpected happens. It would be useful to record what agreements are in place so that everyone understand what they have to do and can have a copy of the information they need.
Hospital Discharge
Being in hospital can be stressful for everyone, especially if someone ends up being in hospital for longer than expected.
Before someone can leave hospital, we need to know that they will be going somewhere they will be safe and they can continue to receive any care they need. This might mean going back home, but having someone stay with them while they recover, or it might mean that we need to talk about alternatives like residential or nursing homes.
For other people, they might be able to live safely on their own, but we need to make a plan to get them there. Maybe we need to ask someone to pick them up, or arrange transport for them.
It can be really helpful if friends and families have already had conversations about how they could support each other if someone was being discharged from hospital. That is why we have made the Plan More, Stress Less toolkit which includes A Plan to Get You Home which people can fill out ahead of time so that everyone knows what the plan if someone is being discharged.
Another important thing to think about when it comes to hospital discharge is Power of Attorney (POA). Having a POA in place can make the discharge process smoother and quicker because soemone is able to make decisions on your behalf. Read more about POA on the webpages.
Power of Attorney
Carer Support Plans
A carer is someone who provides support for a friend, relative or neighbour who could not manage without them. If you think you might be a carer then you should contact your local carer services to find out how they can support you.
There are dedicated carer information pages on our website as well.
What is a Carer Support Plan?
Under the Carers (Scotland) Act 2016, unpaid carers have the right for their needs to be considered separately from those they provide care to. This means that the NHS and HSCPs need to take into account the impact that caring has on you and support you as best they can to help you continue to care if you chose to do so.
A Carer Support Plan identifies what support you need. It is created by identifying what matters to you and what you think will help you to continue to care for someone – these are sometimes called the “outcomes”.
Why should I have a Carer Support Plan?
To look after others, you also need to look after yourself. Having a Carer Support Plan gives you the opportunity to think about what is important to you.
Having a plan allows everyone to easily identify the support that is required to help you meet your desired outcomes. You can continue to build on this plan to reflect the changing needs to help you continue to care.
How can I get a Carer Support Plan?
The easiest way to get a Carer Support Plan is to contact your local carers centre. They will arrange for you to speak with one of the team to talk about what is important to you and how you can best be supported.
To contact your local carer services – find contact detail of your local services.
How much does a Carer Support Plan cost?
A Carer Support Plan is free. All you have to do is contact your local carer support services and they will help you make the plan. To find out where your local services are – find contact detail of your local services.
Wills
What is a Will?
A Will is a legal document which gives instructions on what should happen to your money, possessions and property (all these things together are called your “estate”) after you have died.
It will also identify someone as your “executor” – this is the person who is responsible for following the instructions in the Will and organising your estate. You can have more than one executor.
You can also write a Letter of Wishes to go alongside your Will. This is not legally binding but it can help your executor know what you would like to happen e.g. if you would prefer to be buried or cremated. It might also explain why you have decided to have certain things included in your Will.
Why should I have a Will?
If you don’t leave a Will the law decides how your money, possessions and property are passed on. This might be different from how you would like it to be distributed.
It can also take more time for everything to be sorted out which can be stressful for your friends and family.
How can I get a Will?
There are three main options to choose from:
- Use a solicitor
- Use a will writing service
- Do it yourself
The Money Advice Service has information to help you decide how best to write a Will.
You need to have mental capacity to write a Will so it is better to think about these things as soon as possible. If your circumstances change you can change your Will so long as you still have capacity.
Is a Will and a Power of Attorney the same thing?
No. A Power of Attorney grants someone the legal authority to make decisions on your behalf while you are alive. For more information visit the My Power of Attorney Website.
A Will is a document which gives instructions on what should happen to your estate once you die. A Will is only activated once you die.
How much does a Will cost?
There will generally be a cost involved in making a Will, however it depends on how you make it.
Some people may be eligible for legal aid to help with costs or some solicitors will waive their usual fees at certain times of the year when you donate to charity.
For more information visit the Money Advice Service website or Citizen’s Advice Scotland website.
Supporting Someone At the End of Their Life
What happens when someone is dying?
If you are supporting someone who is dying it can be helpful to know a little bit more about the process and how you can help. NHSGGC have created a leaflet which has lots of information in it. It is called “What Can Happen When Someone Is Dying”. It is also available in other languages on the NHSGGC Bereavement Pages.
The Art of Dying Well website also has useful things to think about. It gives some suggestions of things to think about in order to make the most of the time you have together.
Not everyone will die in hospital. People may be in care homes, hospices or their own home. If someone has an Anticipatory Care Plan it may include where someone would prefer to receive end of life care. It is not always possible for someone to be in that place, however we will all work together to make a plan to make everyone as comfortable as possible.
What happens after someone dies?
People can sometime feel overwhelmed by the amount of things they have to think about when someone dies. There is support and advice available to help you.
Some practical arrangements have changed because of COVID-19. For the latest information please visit the NHSGGC Bereavement Information pages.
Planning Your Own Funeral – What You Need To Know
There are no “right answers” when it comes to planning a funeral. Some people may want to make arrangements before they die, but others might be happy for their friends and family to make these decisions.
You can write a Letter of Wishes to go alongside your Will which will explain what you would like to happen. The Scottish Government have also produced a booklet called “Planning Your Own Funeral” which you might find useful.
If you are arranging a funeral for someone who has died you can find information through Citizens Advice Scotland website.
How much will a funeral cost?
The cost of a funeral can vary.
Some people choose to pay for their funeral while they are alive. This is called a funeral plan. If you are not sure if there is a funeral plan you can
- Check the Will or Letter of Wishes
- Ask the person’s close friends and relatives
- Ask local funeral directors
- Search for funeral plans on the Funeral Planning Authority’s website
You may be able to get help with the cost of the funeral.
Organ and Tissue Donation
From the 26th March 2021, the law about organ donation is changing. Under the new “opt out system”, if all adults aged 16 years and over have not confirmed whether they want to be a donor, they will be considered to be willing to donate their organs and tissue when they die, unless they choose to opt out.
You can still choose whether or not you want to be an organ and tissue donor by registering your decision and telling your family. Your faith, beliefs and culture will always be respected.
We are encouraging everyone to have these conversations with friends and family so that everyone knows each other’s wishes.
You can find out more about organ donation from Organ Donation Scotland. You can also register your decision on the website as well.
You can find out more about tissue donation from Scottish National Blood Transfusion Service website.
You can also watch a recorded webinar about Organ Donation which was recorded in May 2025.
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