e-REDMAP: Care planning in the Community


- Can we talk about what is happening with your health in case you (or people who support and help you at home ) get less well in future?
Would you like anyone close to you be involved?
- It helps to think ahead and talk about what might happen so we know what's important for you.
- Have you talked about planning ahead for changes in your health, treatment or care with anyone before?
- Do you have any kind of plan already? Is there someone who has Power of Attorney for you?
- We can talk about what might happen for (person’s name), and what will be of most help to them.


Can I ask what you know about your health problems?
How have you been doing recently? Has anything changed?
Have you thought about what might happen if you get less well or need more help in future?
Do you want to tell/ask me about anything important for your or your family?


What we know is that… We are not sure about…
We don’t know exactly what will happen or when, but we can plan how to manage your treatment and care.
You need to be in hospital when... You are less well because…
I hope you will stay well/improve with..., but I am worried about…
It is possible something like .... could happen...
If that were to happen, having a plan would help with...
You may have thoughts, questions or worries we can talk about?


What is important to you and your family?
I like to hear about anything we should know to help us care for you as well as we can.
Do you have any ideas about what you would like to happen in the future?
What do you enjoy doing or being able to do? Is there anything you'd like help with now?
Is there anything you don't want to happen or worry about?
What do you think (person’s name) would say about this situation, if we could ask them? Can I ask why they would say that?


What we can do is...
Options that can help you are… That may help, but what could happen is…
This will not help because... That does not work for someone when…
I wish we could do that/give you that treatment… Can we talk about what is possible?
Can we talk about what going to hospital might mean for you?

* Cardiopulmonary Resuscitation (CPR) is always discussed as part of a wider conversation about planning care.
* Make a clinical assessment of CPR outcomes. Is this the time to have a conversation?
* Discuss CPR in line with the person's clinical situation.

Can I ask if you know anything about cardiopulmonary resuscitation or CPR?
Has anyone discussed this with you before?
CPR is treatment to restart the heart and breathing after they have stopped.
- CPR does not work when a person is in very poor health or is dying. It is better for us to plan good end of life care.
- CPR may work but can leave a person in poorer health if they have certain underlying health conditions.
- Some people choose not to have CPR even if it could work for them.
Any other treatments that can help you will be given/continued.
Can we talk about your situation?


We can plan ahead for if/when…
We can make a personal treatment and care plan for you - this is called Future Care Planning in Scotland.
We share your plan securely with other professionals and teams so everyone knows what to do.
All care plans are reviewed regularly; or if your health, situation or wishes change. You can ask for a review at any time.

Sept 2023