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Advance Care Planning in Care Homes (England) Policy

Policy Statement

{{org_field_name}} believes people who use services should have the right to develop an advance care plan if they wish, which outlines the care they want to receive if their physical and mental health declines to the point where they lose mental capacity.

At the height of the Covid-19 pandemic, people having an advanced care plan (ACP) in place or being able to review existing ACPs was of high importance and remains so as we move forward post-pandemic.

All people living in care homes have now been offered Covid-19 vaccinations and this has had a positive impact protecting this vulnerable group and a huge reduction of mortality caused by Covid-19. There remain some people who have chosen not to be vaccinated, so potentially remain at risk of more severe forms of the virus, which is still in circulation.

This care service follows Universal Principles for Advance Care Planning (2022) recommendations which stipulates record keeping and information sharing clear, consistent processes which are understood and supported by all involved in ACP conversations, at individual, organisational and system level. It ensures that key information, ideally in digital format, is transferable between healthcare settings.

As an organisation, this care service is aware it has a responsibility to ensure ACP discussions are approached sensitively. Staff ensure the person is listened to, and actions taken jointly on what matters to the person, how conditions for honouring these can be created and maintained involving individuals, health and care systems.

This care service continues to support the people who use its services to make informed decisions working with general practitioners, community healthcare staff and community geriatricians and other relevant healthcare professionals to discuss emergency care planning and treatment in person-centred discussions.

ACPs may lead to discussion and completion of “do not attempt cardiopulmonary resuscitation” (DNACPR) decisions or Resuscitation Council UK Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms, and people using services and their families will be supported in completion of such.

This policy sets out the home’s approach to ACP and encourages all people using services and their representatives to take part in the process. It is written in line with the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as follows.

• Regulation 9: Person-centred care requires service providers to ensure that the care and treatment of people using services must be appropriate, must meet their needs and must reflect their preferences and wishes. The regulation specifically requires service providers to act in accordance with the Mental Capacity Act 2005 for people who may lack capacity, acting on their behalf where a valid advance decision to refuse treatment is in place.
• Regulation 11: Need for consent requires that care and treatment is only provided with the consent of the relevant person.

Inspectors are prompted in the Key Lines of Enquiry to ask how people are supported to make advance decisions to refuse treatment or appoint someone with lasting powers of attorney, if they wish to do so. This forms part of the five key-question test to rate how caring the service is.

{{org_field_name}} is aware of the CQC report: Protect, Respect, Connect — Decisions About Living and Dying Well During COVID-19 (2021), and understands applying a DNACPR decision to groups of people of any description, referred to as “blanket” DNACPR is potentially discriminatory and unlawful under the Equality Act 2010.

Whilst Covid-19 highlighted issues around DNACPR decisions, these are not new problems and moving forward, this car service will enable people the opportunity to discuss their wishes about care and treatment in a compassionate and person-centred way.

{{org_field_name}} is mindful of the Universal Principles for Advance Care Planning (2022), implementing recommendations of the CQC report into the use of DNACPR decisions taken during the Covid-19 pandemic, and follow the values of: inclusion, equality and diversity country wide.

{{org_field_name}} ensures comprehensive documentation is maintained relating to DNACPR decisions, including sharing of information and records of compassionate conversations and decisions agreed with the person, their families and representatives to enable them to move around the system well.

When implementing a DNACPR, {{org_field_name}} ensures this is done following individual assessment of each situation, in consultation with the individual and their family. When a DNACPR decision is made individuals are informed when it will be reviewed, which will be each time individual’s situation changes and such information recorded.

Reasonable adjustments are made for disabled people to remove any information or communication barriers. Clear information about ACP is made available in accessible formats and languages.

The Care Quality Commission (CQC) is introducing a new regulatory approach for health and care providers, integrated care systems and local authorities. These changes reflect the evolving landscape in health and social care. Whilst on-site inspections remain essential elements of performance assessments and the opportunity to observe the care people receive, they are not the only way the CQC will assess quality.

As part of their aim for a consistent national approach to end-of-life care, {{org_field_name}} understands the CQC will continue to monitor DNACPR decisions, including whether these are carried out in a safe way that protects people’s human rights with an expectation that individuals are at the centre of their care.

This care service understands personalised and compassionate advance care planning, including DNACPR decisions, is a vital part of good quality care and that, done properly, it can offer reassurance and comfort for people and their loved ones.

Advance care planning is also in line with the Mental Capacity Act 2005 which creates statutory rules with clear safeguards so that people may take decisions in advance to refuse treatment if they should lack capacity in the future.

Where a person lacks the capacity, this care service follows guidance that it is reasonable to produce such a plan following best interest guideline with the involvement of family members or other appropriate individuals.

Currently there is no relaxation of Deprivation of Liberty Safeguards (DoLS) associated with the pandemic and care homes should ensure that they adhere to DoLS guidelines until such time as new safeguards are in place. The home understands DoLS are to be abolished and replaced with the Liberty Protection Safeguards (LPS).

This system will apply to England and Wales only and the original implementation date for LPS of 1 October 2020 was postponed until April 2022, and the Government announced in December 2021 that the planned implementation date for LPS for April 2022 could not be met. There is no new implementation date set at this time.

Definition

Advance care planning (ACP) is a voluntary process of person-centred discussion between an individual and their care providers about their preferences and priorities for their future care.

ACP is a process of thinking ahead to the decisions that a person should take if their physical and mental health declines to the point where they lose mental capacity. ACP is, however, much more about looking ahead more generally, so that appropriate care and other provisions can be properly planned and made at the appropriate time.

The policy works on the reality that many people who move into a care home will live there for the rest of their lives and will experience a progressive decline in their physical and mental condition.

It implements its policy on ACP in line with other policies on end-of-life and palliative care. In doing so, the home is seeking to improve its standards of end-of-life care in line with government policies and end-of-life care strategy programmes.

The discussions and decisions involved in ACP include:

• identifying a person’s wishes for their future if their condition deteriorates or they come to the end of their life and what is important to them in terms of their personal, religious and cultural values
• helping the person to understand more fully their physical and mental health and specific illnesses and conditions and the effects and implications
• identifying the person’s preferences for the types of care or treatment that they feel they would want in the future, particularly at the end of their life
• identifying the person’s wishes or instructions over their after-death and funeral arrangements, particularly if they do not have family or there are differences of views between the family members
• making an advance directive on future care and treatment under the provisions of the Mental Capacity Act 2005.

The home works on the basis that any individual at any time can develop an advance care plan. For example, someone with a terminal illness might record that they wish to die in {{org_field_name}} rather than in hospital. The home will take this wish into account if such a decision must be taken and the person is unable to make their wishes known as clearly at the time.

ACPs will be accessible and recorded in such a way that healthcare professionals can easily access in emergency situations. A paper copy will be kept in care home records and, where feasible, a digital copy or electronic version which may be shared with relevant services. Advance care plans should be shared with the primary care out-of-hours service.

Advance care planning or reviews may include discussion around and completion of a DNACPR or ReSPECT form with healthcare professionals.

Any decisions would be made on an individual basis, according to need.

This care service believes it is unacceptable for ACPs with or without DNACPR form completion to be applied to any groups of people using services.

The ACP Process

1. Those who would benefit from ACP are identified, with the opportunity provided for the person to prepare for the future and make their priorities and preferences known, respecting their choice not to do so if that is their wish or if they are not yet ready.
2. {{org_field_name}} has a policy of including ACP in a person’s overall plan of care so that it is made clear what the individual’s wishes are in advance of the occasions that they need to be implemented.
3. Discussions with the individual are held at the earliest stage possible, taking into account the sensitivity of the subject matter, which makes it necessary to proceed at the person’s own pace and only when they accept the idea and give their consent to discussing the issues.
4. The home’s experience is that many residents are proactive in their thinking and welcome the opportunities afforded by the ACP process to make clear their wishes and views on future and end-of-life issues.
5. However, many ACP discussions take place when it is anticipated that a person’s condition will deteriorate to the point where he or she loses their capacity to make decisions to communicate their wishes to others.
6. The home is careful to record and recognise the validity of any advance directives as defined by the Mental Capacity Act 2005. For example, a person might have taken a decision to refuse specific medical treatments, such as being resuscitated after a major heart attack, or being admitted to hospital again. This type of directive will come into effect if the individual loses capacity to give or refuse consent at the time the treatment decision is required.
7. The home also works closely with advocates and representatives who already hold powers of attorney at the time of admission or after, to try to ascertain the person’s future wishes and needs, when they might have already lost the capacity to communicate them. The outcomes are recorded on the plan of care, as are other decisions, and are fully respected.
8. {{org_field_name}} recognises, respects and supports the diverse needs of people with different faiths, cultures and circumstances and ensures these are accurately reflected in the ACP.

ReSPECT summary plan to support ACP process

This care service is aware of the Resuscitation Council UK Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) being used where clinicians feel it to be appropriate.

Resulting clinical recommendations, which potentially include, for example, whether or not to be taken to hospital, whether or not to be admitted to ITU or placed on a ventilator may also be recorded on a ReSPECT form, which records recommendation for CPR.

When clinicians are considering making a DNACPR recommendation there is a legal requirement for them to discuss this with the person in their care or those close to them if they do not have capacity for that discussion.

Procedures followed in the ACP Process

1. {{org_field_name}} recognises that ACP needs to be carried out sensitively and at the person’s own pace.
2. Where possible, the home includes ACP discussions before a person comes into the home as part of the person’s needs assessment. It does this by, for example, asking the applicant and their relatives to identify their wishes and preferences regarding future care so that there are agreements in advance on the courses of action to be taken. Some families find this difficult but where carried out it helps to reduce the conflicts of interest that frequently arise when decisions based on assumptions about what the person might or might not want have to be taken.
3. The home includes in its care planning documentation the recording of all ACP discussions and decisions.
4. {{org_field_name}} recognises that some people do not wish to discuss these matters at all and fully respects their wishes.
5. It also recognises that some people might have already made advance care plans before admission and these form the basis of further discussions with home staff.
6. The home tries to integrate advance care planning discussions into the wider care planning and reviewing process. It keeps these issues under regular review, recognising that people can change their minds as their physical and mental health changes.

Training

Managers and care staff have an important role to play in supporting people to consider advance care planning and should receive training to enable them to do so. The home requires staff involved in care planning particularly key workers to be confident and well trained in the principles, purpose and process of ACP so that they can include these issues in their ongoing work with people using services and their representatives and other professionals.

{{org_field_name}} is aware of Universal Principles for Advance Care Planning (2022) and that ACPs must incorporate personal values, faith and culture, supports personalised planning for future care, prevents unlawful discrimination and promotes equality.

Staff involved in such discussions will have a full understanding of the Mental Capacity Act 2005, including how and when to assess capacity and make decisions in someone’s best interests.

Staff involved in DNACPR decisions will have the knowledge, skills and tools to deliver personalised approaches in accordance with relevant legislation and are aware of mechanisms to raise concerns.

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