*** Please scroll down to access Advance and Future Care Planning Forms, COVID-19 Treatment Escalation Plan and for Covid-19 updates ***
This page includes information and links for Advance and Future Care Planning.
These resources and forms are for patients and healthcare professionals, with the aim of providing a One Wales sharing and involving approach.
The documents have been peer reviewed by the Advance and Future Care Planning Strategy Group (AFCP) for Wales, which sits under the auspices of the NHS Wales End of Life Care Board and the Deputy Chief Medical Officer for Wales.
The decision making to inform these forms involved extensive patient and carer engagement.
The AFCP Group has patient representation and is pan-Wales. It has also been informed by data collated during a National Future Care Planning Conference in Wales.
Advance and future care planning is predominantly about frank and honest conversations, delivered compassionately.
Being able to document such discussions, however, is also important, and resources must be instantly recognisable by doctors, nurses and paramedics when they arrive in an emergency.
The title of the form links to the latest version, and we have included a short description for reference and guidance notes where relevant.
Two of the forms can be patient facing, and healthcare professionals in Wales may wish to provide this page link to individuals who wish to fill in such prior decisions.
Both the All Wales Advance Decision to Refuse Treatment Form (ADRT), which is legally binding, and the Statement of Wishes Form (RACPAP), are filled in by patients, usually after explanatory discussions with healthcare professionals, and for clarity, they may be initiated by healthcare practitioners (HCPs) and can be filled in together.
Two further forms are available, a Future Care Planning form that can be filled in by healthcare professionals after attempts at wide consultation with a person’s next of kin or independent mental capacity advocate (IMCA), in order to establish and write down what said individual, who currently lacks capacity to make certain decisions, would have wanted or declined.
Only the ADRT is legally binding, the other forms are for decision guidance only, in essence a letter to a future person who may be involved in that individual’s urgent care, to elicit prior views, conversations and preferences.
We also recommend that individuals in Wales consider appointing a Lasting Power of Attorney (LPA) for Health and Welfare, who can act on their behalf if they lose mental capacity.
An LPA can be one of the more powerful ways to ensure that future treatments are discussed with a trusted individual(s) and it is legally binding.
For information about how to set this up, contact the Office of the Public Guardian.
Also, the Older People's Commissioner in Wales has produced useful guidance here: An Easy Guide to Lasting Powers of Attorney.
The hospital/inpatient Treatment Escalation Plan (TEP) on this page was developed by Aneurin Bevan University Health Board in April 2020 in response to the pandemic. It has been reviewed by the AFCP Group and the Deputy CMO, and can be used in all inpatient settings in Wales. Again, this is merely a guide for practitioners to indicate what ceilings of treatment have been suggested and discussed previously and, importantly, it is a short-term document for one specific episode of care. Its recommendations may change daily if patient's health/frailty improves or worsens.
This is the All Wales Advance Decision to Refuse Treatment form as a PDF. It is possible to type into this PDF, but it requires ‘wet signatures’ at the end.
This is filled in by patients, and the signing needs to be witnessed and counter-signed. Please see the guidance notes for further information. We have adapted this form with kind permission from a charity, and it is the same format that NHS England recommends and is compliant with the Mental Capacity Act 2005.
This is not legally binding, but where patients have filled this in and ideally discussed details of it with their HCP, it provides a strong direction for future care and is valuable information in an emergency.
This PDF form can be used to type into, and is signed by the patient (optional, as some people may find the act of signing such a document troubling).
It is signed by a Healthcare Professional who has helped or had sight of the form, in order to then include it in contemporaneous health records and share appropriately.
These forms may be suggested by nurses, doctors and other HCPs, and can be filled in together and filed or scanned into all contemporaneous notes, ideally prominently at the front, together with other forms, such as existing DNACPR forms.
Patients can also prompt their healthcare professional contact to help them fill these forms in.
The above document is short, concise and very specific, and has a very clinical direction. For a widely recognised Advance Care Plan document that has a softer focus and deals not just with medical wishes/views, but also other areas, we recommend using Powys Teaching Health Board's My Life My Wishes documents and guidance notes.
These have won widespread praise, have been through governance processes and are a Bevan Commission Exemplar project. Powys Teaching Health Board has kindly agreed to its use across any part of Wales.
This form, whilst not legally binding, never-the-less records conversations and views obtained with regard to future care scenarios, and can be useful when an individual lacks decisional capacity.
All efforts should be made to obtain as much information from this individual, and mental capacity can significantly fluctuate even from day to day, so the individual must be at the centre and repeat attempts should be made and documented.
Where this is challenging or not possible despite best efforts, including providing hearing aids or translators, for instance, then those close to the patient should be consulted to help elicit what the person may have wanted in given situations.
An independent mental capacity advocate should be appointed/consulted in situations where next of kin and proxy cannot be found.
A Treatment Escalation Plan (TEP) form has been developed by Aneurin Bevan University Health Board, and has been adapted since the Covid-19 pandemic began.
It has been approved to carry an All Wales NHS Wales logo by the Deputy Chief Medical Officer. It is for use in hospitals and inpatient settings only, and is time-limited to the acute episode in question. Even within that acuter episode the TEP can change (sometimes daily) in light of recovery or deterioration.
Access the TEP form/resources by clicking here (and scroll down to middle of page).
TEPs are not legally binding and should be limited to the episode of care and with frequent reviews. So a person’s levels of escalation may change if they improve or deteriorate. TEPs should not be forwarded to community settings, as their initial frailty assessment is linked to the specific admission they pertain to.
They can provide guidance and structured handover of decisions and conversations that have been held, and can reference much longer annotations in the contemporaneous notes.
TEPs should be discussed with patients and/or those close to them, unless there is a risk of causing harm by holding this discussion.
All of the above information can only work well with the appropriate ‘scaffolding’, so where conversations have occurred in one setting, it is important that they are not ‘lost’ to other settings and teams.
Appropriate local policies to share this information safely, set out by local health boards should be in place, and community settings, ambulance services and out-of-hours providers must not be left out.
Where there are local Advance and Future Care Plan schemes in place already, these can be continued and adhered to in line with LHB and Trust guidance. We suspect that gradually, however, teams and patients will start using the All Wales documents increasingly, as everyone becomes more accustomed to the forms.
In a home situation, there is the Lions Club Message in Green Bottle scheme, which is well established in Wales: paramedics look for a green sticker inside the front door routinely when they go on house calls, which alerts to the presence of a green bottle in the person’s fridge. Then they know there is something important they have to check for.
Anyone can put their DNACPR form or ADRT in a green bottle in the fridge, or a written instruction as to where to find all these important forms in the house - for example, 'My DNACPR is in living room on bottom left shelf.'
The Lions Club supplies the bottles to health centres, doctors’ surgeries and chemists, but other green bottles can also be used.
The green Lions Club bottles and stickers are also available directly from Lions Clubs. Call 0845 833 9502 for details of your local club.
For more information on advance future care planning, including educational videos and definitions.
For information and video resources on DNACPR conversations.
A brief update video presentation on the current law regarding DNACPR and Advance and Future Care Plans by barrister Alex Ruck Keene.
Module: DNACPR and Advance Care Planning in Wales - updates 2021 (1 CPD credit)