e-REDMAP: Anticipatory care planning in the Community

Ready

- 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.

Expect

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 are seriously ill in future?
Do you want to tell/ask me about anything important for your or your family?

Diagnosis

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 are less well than before because…
I hope you will stay well/improve with..., but I am worried about…
It is possible you will not get better...
If that were to happen, having a plan would help with...
You may have thoughts, questions or worries we can talk about?

Matters

What is important to you and your family?
Can we talk about how you would like to be cared for in the future?
What things would you like to be able to do?
Is there anything you don't want to happen or wish to avoid?
What do you think (person’s name) would say about this situation, if we could ask them?

Actions

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 discussed as part of a wider ACP conversation.
* Make a clinical assessment of CPR outcomes.
* 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?

Plan

We can plan ahead for if/when…
We can make a personal treatment and care plan for you - this is called anticipatory care planning in Scotland (ACP).
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.

Dec 2021

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