Planning for Care

If you would like to keep up to date with developments then you can join our mailing list.

A Future Care Planning Champion can be any professional who has an interest in helping us create a culture of open and honest conversations about future planning.

If you would like to find out more you can download this Role Description.

To become a Future Care Plan Champion please register. Please note you will need to have permission from your Line Manager before becoming a Future Care Plan Champion.

If you are a professional and have an interest in this area, you might be interested in joining our Clinical Advisory Network. This network offers comment and feedback to help us create the right resources for staff. 

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.

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 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. 

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.

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 ACP 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”.

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 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)

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.

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 or you can email ACPSupport@ggc.scot.nhs.uk.

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.

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

*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: Anticipatory 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

Please note you will need to make an account. 

Suggested Courses: 

Changing children’s attitudes to death

Working with children pre-bereavement

Coronavirus: Communication and Difficult Conversations

Palliative and End of Life Care including Bereavement

Personalised Care and Support – Building on the Recovery Package

Supporting Carers: A Professional’s Toolkit

NHS Education for Scotland (NES) Resources

Please note you may need to make a TURAS account to access these resources. 

Suggested Courses:

Realistic Conversations – Shared Decision Making

Developing Practice Module 2

Building a Shared Understanding

Informed about palliative and end of life care

Other Resources

EC4H (Effective Communication For Healthcare)

Difficult Conversations – Talking About Death and Dying (Video)

SPICT Tools

Delivering Bad News Video – Irish Hospice Foundation

Take some time to think about what matters to you and who matters to you.

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.

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.

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.

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.

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.

What is a Future Care Plan?

Future Care Planning is about thinking ahead and understanding your health. It’s about knowing how to use services better and it helps you make choices about your future care.

This is a process and should involve ongoing conversations between you, the people that matter to you and the health care professionals involved in your care.

We will discuss what is important to you and what living well means to you. We will discuss what treatments you would like and which treatments you would not like. We will also discuss where you would prefer to have this treatment. We might discuss end of life care with you. By talking about all of these things we can all work together to make individual treatment plans that respect your wishes.

We can record the decisions made during these conversations in a Future Care Plan.

Here is a short video explaining all about Future Care Planning.

Why should I have a Future Care Plan?

Having a record of your wishes can help in many ways.

It can help you think about what is important to you and give you an opportunity to share this information with the people who matter to you.

It can help the people who matter to you understand your wishes. This means that if they have to make decisions on your behalf, they can be confident that they are making the same choice as you would. If they are your welfare Power of Attorney, they may be legally responsible for making these decisions if you lack capacity. If you do not have a Power of Attorney they can still speak with members of your health care team to let them know what you would want, however your health care team have legal responsibility to make these decisions. 

It can help your health care team understand what is important to you so that they can work with you to make treatment plans that respect your wishes. If you no longer have capacity to make these decisions, then your health care team can use your Future Care Plan to make decisions that best reflect your wishes. 

It can help everyone by giving them an opportunity to have open and honest conversations with each other. It gives you and the people that matter to you and opportunity to ask any questions you may have. It also gives your health care team the opportunity to make sure that you understand what is happening with your care and work with you to make appropriate decisions.

What goes in a Future Care Plan?

Future Care Planning Conversations can cover a range of topics. We can use the word “DISCUSS” to help everyone remember the different topics that are part of Future Care Planning.

It might not be appropriate to talk about all these things at once, and there might be some things that we never get to speak about. That is okay. Everyone can go at their own pace, and we will never force people to have a conversation they are uncomfortable with.

You do not need to speak about these topics in a particular order, so if it helps, you can start off with easier conversations and work your way up to the bigger issues.

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

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.

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.

What is a Power of Attorney (PoA)?

A Power of Attorney is a legal document which gives someone else the authority to make decisions on your behalf if you are unable to do so. This person is called your attorney. You can ask anybody that you trust to be your attorney. 

There are two types of Power of Attorney:

• Welfare Power of Attorney – someone has the authority to make decisions regarding your health and welfare.
• Financial Power of Attorney (also called a Continuing Power of Attorney) – someone has the authority to make financial decisions on your behalf.

You can choose different people for different types of PoA, or they can have both. You can also choose to have more than one attorney (however they would have to make the decisions together).

You can choose when you want your Financial Power of Attorney to be activated – you might decide to activate this before you lose capacity. Your Welfare Power of Attorney will only be activated when you lose capacity.

What does it mean to “lose capacity”?

If you lose capacity, it means that you are no longer able to look after your own financial and personal affairs. There are lots of reasons why this could happen. Some medical conditions which can affect your capacity are dementia, delirium or a stroke.

In Scotland, anyone over 16 is usually considered to be an adult. This means they can make decisions for themselves and manage their own affairs. Therefore to “lose capacity” there must be medical evidence that you are not able to do this.

There are lots of things that might happen to show that someone has lost capacity. These include not being able to:

• act on decisions
• make decisions
• communicate decisions
• understand decisions
• remember decisions

Can my family make decisions on my behalf without a Power of Attorney?

Many people think that if you lose capacity, you can rely on members of your family (such as a husband or wife) to act on your behalf. Unfortunately, unless you have a Power of Attorney arranged, this is not the case. Nobody automatically has the right to make decisions for you unless you have granted them Power of Attorney in advance. If no one is legally appointed by you to act, then no one has legal authority to do so. This means that, although your nearest relatives may be consulted about your wishes, they cannot decide what should happen to you if you haven’t given powers in advance.

If you have not granted powers in advance, and you lose the capacity to make your own decisions, then the courts have to appoint someone to be your Guardian. There are processes by which family members can apply to be granted these powers after someone has lost capacity, but this is a long, expensive process and requires a court hearing. Carer Information Scotland have more information on the guardian process.

How can I get a Power of Attorney?

You need to assign someone as your attorney whilst you still have the capacity to do so.

The first thing to do is speak to the people who matter to you and discuss with them why you want to organise this. It helps if everyone understands why this is important to you and can help you with the process if necessary.

Next, decided who is going to be your attorney. Remember there are two types – Welfare and Financial. You can have different people for different roles and you can have more than one person acting on your behalf.

Once you have decided who is going to be your attorney you need to register the appropriate documentation with the Office of the Public Guardian. As this is a legal document it is very important that everything is carried out correctly. Most people use a solicitor or lawyer to help them with the process.

How much does a Power of Attorney cost?

There is a cost involved in registering a Power of Attorney. There may also be a cost for legal fees. You may be eligible for help with covering these costs. The Citizens Advice Scotland have further information about costs and legal aid.

You can also visit the My Power of Attorney Website. 

I have a Power of Attorney. Do I need to do anything else?

Yes! You also should have conversations with your attorney so they know and understand what matters to you and what your wishes would be if you no longer had capacity to make decisions.

If they are responsible for your welfare, this will only be active once you have lost capacity. This means that they may not be able to have a proper conversation with you at that time and will have to decide things for you. It is much easier to make these decisions if you have already discussed these and they feel like they know what your wishes are.

Together you may want to make a Future Care Plan which is a written document of your wishes.

You should also let any health care professionals involved in your care know who your attorney is. This information can then be stored on their systems in case they need to contact them.

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.

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. 

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.

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. 

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.