Core Component 3: Anticipatory Care Planning

Core Component 3: Anticipatory Care Planning

 

Adopting a “What, Why, Who and When” approach to anticipatory care planning, can be used to encourage meaningful conversation about what a person would like, what they don’t like and how best to care for them during periods of change. This might be associated with deteriorating health, personal care and/or personal circumstances. This timely approach supports the creation of individualised, evolving, anticipatory care plans (ACP). Sometimes referred to as advanced care planning.

The Anticipatory Care Plan (ACP) should be created in partnership with the patient, carer and key professionals involved in their care. It should reflect an evolving discussion about:

  • Patient and carer understanding of how things are now and their expectations going forward.
  • Current cardiological and comorbidity status.
  • Realistic goals of care.
  • Care preferences: appropriate goals of care, place of care and place of death. Place of care and death may differ e.g. home may be the preferred place of care with hospital, care home or hospice being the preferred place of death.
  • Cardio-Pulmonary Resuscitation Status.
  • Timely deactivation of cardiac devices if appropriate (ICD or CRT-D).
  • Admission avoidance guidance to support the community and/or out of hours’ team, in minimising symptoms which have previously triggered a hospital admission.

The ACP should be shared with all key clinicians involved with the patient’s care and a copy should be given to the patient with their consent to be kept at home. Remember this should not be a one time conversation and the preferred care wishes may change in response to changing physical, psychological, social and or carer needs.

Key Message: The ACP is an evolving, meaningful discussion between the patient, their carer and key clinician which is often the heart failure nurse. This discussion should focus on ensuring that everyone is able to live well, knowing that their wishes have been heard and will be respectfully implemented in response to inevitable change.

Click here to find out about Component 4: Cohesive Working

Key Message: The ACP is an evolving, meaningful discussion between the patient, their carer and key clinician which is often the heart failure nurse. This discussion should focus on ensuring that everyone is able to live well, knowing that their wishes have been heard and will be respectfully implemented in response to inevitable change.

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(c) British Society for Heart Failure, 2022-
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