e-RED–MAP: Anticipatory care planning in the Community

Ready

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

Expect

Can I ask what you know about your health problems?
How have you been doing recently, and 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?

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…
If that were to happen, having a plan would help with...
Do you have any thoughts, questions or worries I can help with?

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 would you like to be able to do?
Is there anything you do not want to happen or wish to avoid?
What would he/she say about this situation, if we could ask him/her?

Actions

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

Where appropriate, Cardiopulmonary Resuscitation (CPR) should be discussed as part of a wider ACP conversation. Make a clinical assessment of the medical outcome of CPR for this person. Discuss CPR outcomes in line with their clinical situation.

Can I ask if you know anything about cardio-pulmonary resuscitation or CPR?
Has anyone discussed this with you before?
CPR is treatment to restart the heart and breathing.
- CPR does not work when a person is in very poor health or dying, so it is better for us to plan good care.
- With these health problems, CPR may work but can leave the person in much poorer health. Can we talk about your situation?
Any other treatments that can help will be given.”

Plan

We can plan ahead for if/when…
We can make a personal plan for you called an anticipatory care plan (ACP) and share it securely with other professionals and teams so everyone knows what to do.
Any care plans we make are reviewed if your health or situation change, and you can ask for a review at any time.

April 2021

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