Synopsis
Offer voluntary and revisable planning that records values, communication preferences, lawful decision-makers, treatment refusals and emergency recommendations, while preserving capacity, current choice and jurisdiction-specific legal safeguards.
- Advance care planning is a voluntary process of exploring and recording what matters if health worsens or communication becomes difficult.
- Start first-line with values, understanding, worries and preferred decision support; introduce legal forms only after establishing what the person is trying to achieve.
- Capacity is presumed, specific to the decision and time, and must be supported with accessible information, interpretation and treatment of reversible impairment.
Key red flags
Advance planning must never be imposed as a condition of treatment, discharge, social care or access to palliative services.
Reluctance to speak alone, language mirroring another person or unexplained pressure about treatment or inheritance warrants private and safeguarding assessment.
Investigation priorities
Establish whether the person wants to plan, what matters, what they fear and which future decisions feel relevant.
Management branches
A person with capacity is willing to discuss possible future deterioration or loss of communication.
- Explore understanding, priorities, feared outcomes, trusted people and preferred communication before discussing specific forms or treatments.
- Explain separately the roles and limits of an advance statement, advance refusal, attorney, DNACPR and broader emergency-care recommendation in the relevant jurisdiction.