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Policy Statement

This policy sets out the home’s approach to advance care planning (ACP) and advance decision to refuse treatment (ADRT) encourages all people using services and their representatives to take part in the process. This policy conforms to the requirements of the relevant Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2019 relating to needs assessments, individual plans of care, decision-making and mental capacity, and the Social Services and Well-being (Wales) Act 2014 which requires local authorities and care providers to put the needs of the individual at the heart of their helping efforts.

This home refers to NHS Wales Advance & Future Care Plans, which have been reviewed post-pandemic and may be used in all inpatient settings in Wales, as a guide for practitioners. The following template forms may also be downloaded.

• Advance Decision to Refuse Treatment (ADRT).
• Statement of Wishes.
• Future Care Planning.

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 people using services, usually after explanatory discussions with healthcare professionals, and for clarity, they may be initiated by healthcare practitioners (HCPs) and can be filled in together. For more information see Advance and Future Care Plans on the NHS Wales Health Collaborative website.

Definition

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 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.

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.

An advance decision to refuse treatment (ADRT) is a written, witnessed decision to refuse a specific type of medical treatment and may also be referred to as an advanced decision or living will. Whilst an ADRT is not the same as an advance care plan, it may form part of an ACP but must be documented in a specific way.

The legislative framework for ADRTs is complex, and health or social care professionals working with people living with life-threatening or long-term conditions may not have the experience or knowledge to help an individual who is asking about ADRT. Where ADRT discussions lead to refusal of life-sustaining treatment, healthcare professionals should ensure that the advice given reflects the requirements of the Mental Capacity Act 2005.

The responsibility for making an ADRT belongs to the person (the maker) of such. There is a need for staff to support the person using services to distinguish between “care planning” and “advance care planning” and appreciate areas of overlap.

{{org_field_name}} is aware of All Wales Advance Decision to Refuse Treatment form is available as a PDF and that whilst possible to type into this PDF, it requires “wet signatures” at the end. This legally-binding form, which documents refusal of future interventions form is completed by the person using services, and the signing needs to be witnessed and counter-signed and is compliant with the Mental Capacity Act 2005.

Individuals, however, cannot refuse care to ensure their comfort, such as keeping them warm and safe, giving food or water by mouth. Nor can they ask anyone to help them to help to end their life.

{{org_field_name}} is clear — for the person using services, deciding to refuse a treatment is not the same as asking someone to end their life or help them to end their life. Euthanasia and assisted suicide remain illegal in the UK.

{{org_field_name}} also acknowledges if the person using services is transgender, non-binary or gender queer and subsequently on hormone therapy, they may need support to consider incorporating treatment wishes into their ACP. It might be a consideration for some conditions as to whether the person can have their hormone therapy alongside other treatment. Appropriate healthcare professionals can help the person explore concerns and inform and support plans and options appropriate to meet their needs, such as changing from tablets to a gel or patch, if the person suffers from swallowing issues.

{{org_field_name}} continues to support people 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.

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.

This home recognises, respects and supports the diverse needs of people with different faiths, cultures and circumstances, and ensures these are accurately reflected in the ACP.

As a consequence, advance care plans may result in the discussion and completion of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) or Resuscitation Council UK Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms.

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.

Where a person using services lacks the capacity, {{org_field_name}} follows guidance that it is reasonable to produce such a plan following best interest guideline with the involvement of family members or other appropriate individual.

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.

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 the care home 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.

This care home staff ensured support is sought from GPs and primary care teams, with specialist input where necessary to answer queries and provide as much information and support as possible.

{{org_field_name}} is aware that decisions to admit to hospital will be undertaken in collaboration with paramedics, general practitioners and other healthcare support staff. Transfer to hospital may not be offered if deemed unlikely to benefit the individual. If palliative or conservative care within the home is considered more appropriate, this care home will work with healthcare providers to facilitate this.

{{org_field_name}} continues to work with GPs and local pharmacists to ensure that they anticipate palliative care requirements and anticipatory medications procured as required.

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

For an ADRT, the guidance will be followed in Advance and Future Care Plans. {{org_field_name}} will ensure the document is safely stored, and the manager will ensure a current copy is retained and is recorded in the person’s healthcare records to enable it to be shared with relevant healthcare professionals.

Advance care planning or reviews may include discussion around and completion of a DNACPR or Resuscitation Council UK Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms. In some circumstances, eg absence of clinical progress in cases of Covid-19, the likelihood of benefitting from CPR needs consideration.

Any decisions would be made on an individual basis, according to need. The GP has a pivotal role in this process for those in care homes or community settings.

{{org_field_name}} 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. This home 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.
2. 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.
3. The home’s experience is that many residents are forward looking 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.
4. 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.
5. The home is careful to record and recognise the validity of any advance directives as defined by the Mental Capacity Act 2005 and encourages people using services to think about such matters within the ACP process. 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.
6. 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.

Procedures followed in the ACP Process

1. The home 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. The home 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.
7. Where the person expresses a wish to have an ADRT, the home will ensure they are signposted to relevant healthcare professionals to ensure they receive proper medical advice about the implications.

Training

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.

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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