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Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly

Advance Care Planning

advance care planning

Advance Care Planning refers to a process of discussion and reflection about goals, values and preferences for future treatment in the context of an anticipated deterioration in the patient's condition with loss of capacity to make decisions and communicate these to others.


Advance care Planning may lead to making an Advance Statement, or Advance Healthcare Directives such as an Advance Decision to Refuse Treatment (ADRT), a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision, or other types of decision (such as making a Lasting Power of Attorney).

Read more about the differences between General Care Planning, Advance Care Planning, and Advance Healthcare Directives.

Advance Statement

Advance Statement Template

Template for the recording of Advance Care Planning decisions.

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UFTO int'l

Universal Form of Treatment Options

Template for the recording of Advance Care Planning decisions for use in Hospital settings.

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ADRT int'l

Advance Decision to Refuse Treatment

Template for the recording of Advance Decision to Refuse Treatment

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Portable Medical Orders

previously known as Physicians Orders for Life-Sustaining Treatment

Template for out of hospital doctor’s order that indicates patient preferences for resuscitation and scope of treatment, intended to be completed for seriously ill or frail patients and to be followed by emergency medical providers.  

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Do Not Attempt Cardio Pulmonary Resuscitation

sample templates from England, Wales, Scotland

Template for the recording of a DNACPR decision

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The freedom to decide one’s own destiny is the right of every competent person, and this includes the right to accept or refuse medical treatments.

There is evidence that people with advance care plans receive less aggressive interventions in the last phase of life and may spend less time in hospital. 

Good quality patient-centred end of life care also helps families through their care of terminally ill loved ones and their bereavement.

Read more about Good Quality Patient-Centred End of Life Care



It is important that Advance Care Planning become part of routine clinical practice so that patients' wishes and preferences for health care, particularly end of life care, are known and met.

Advance Care Planning can be part of a health care discussion with patients of all ages within the primary care environment or hospital setting.

The planning process respects the patient's right to take an active role in their health care, in an environment of shared decision-making between the patient and doctor.

It may involve family members, religious advisors, friends and other people the patient feels should be involved.


An Advance Care Planning discussion with a person includes:

  • The persons and/or family’s concerns or worries about any aspect of end‐of‐life their values and personal goals for care at this time

  • Their understanding about  their illness and prognosis  

  • Their preferences for types of care/treatment that may be beneficial in the future.


True person‐centred care means taking the time to find out what the person (patient) wants to know and what are their preferences are regarding their end of life care.  


Decisions to be considered may include:

  • CPR (cardiopulmonary resuscitation)

  • ventilator use

  • artificial nutrition (tube feeding) or artificial hydration (intravenous fluids)

  • comfort care



An Advance Care Planning discussion should be considered in the following circumstances:

  • When it is clear the patient has a life‐limiting advanced progressive illness

  • When you can answer ‘yes’ to the following question ‐ “would you be at all surprised if this   patient was alive in 12 months’ time?”

  • If the patient/family have expectations which are inconsistent with clinical judgment (for example, the person thinks that they will able to live independently again)

  • When there is a significant deterioration in the patient’s condition

  • When a treatment decision needs to be made

  • If disease‐specific treatment is not working

  • At the time of referring the patient to specialist palliative care services.



Good communication skills are required, as well as specific understanding of the sensitive issues at hand, the laws pertaining, and the local resources available. 

Training for this may be required. 

It may take several meetings with the patient (and their family if they wish and give consent) to complete the discussion.

Read more about Recommended Practice and Sample Phrases

In order to best serve the interests of the individual, and to avoid medicolegal pitfalls, the healthcare provider assisting the individual with Advance Care Planning, Advance Statements and Advance Healthcare Directives should carefully follow the approved process for making best decisions in serious medical conditions in patients over 18 years.

Read more about the Approved Process for Making Best Decisions in Serious Medical Conditions in Patients Over 18 Years

When faced with an Advance Statement or Advance Healthcare Directive in clinical practice, the healthcare provider should similarly check the validity of the document by working through the Advance Decision Validation Checklist.

Read more about the Advance Decision Validation Checklist.

Mental Capacity


There are two stages to the test of capacity:

  • The patient cannot make a decision due to a condition of mind or brain

    For older people this is most often due dementia or delirium, but may also be due to other conditions such as learning difficulties or severe depression

  • The person cannot understand, retain, weigh up, or communicate information relavant to the decision in question.

Both parts of the test must be satisfied in order to state that capacity is lacking. 

The reasons must be clearly documented.

Decisions and actions carried out under the U.K. Mental Capacity Act 2005 should be tested against the 5 key principles set out in Section 1 of the Act.

Read more about the Assessment of Mental Capacity

Advance Statement


Advance Statements should be reviewed as the patient's condition, and possibly treatment preferences, change.

Patients should be urged to communicate any changes in their Advance Statement to their GP provider and other relevant healthcare provider.

Doctors should record relevant discussions with the patient and any changes to the Advance Statement in the patient's medical record, including both the local health record (encompassing the practice as well as the hospital).

A Universal Form of Treatment Options (UFTO) is available for use in Hospital settings.

An advance statement - unlike an advance decision - is not legally binding, so doctors and medical professionals do not have to follow it. However, it should still be taken into account by health and social care professionals when making decisions about care and treatment.

Read more about Advance Statement

Providing Comfort at the End of Life


Comfort needs near the end of life include:

  • Physical Comfort

    • Pain

    • Breathing problems

    • Skin irritation

    • Digestive problems

    • Temperature sensitivity

    • Fatigue

  • Mental and Emotional Needs

  • Spiritual Issues

  • Practical Tasks

Read more about Providing Comfort at End of Life

ADRT Directive


An Advance Decision to Refuse Treatment is a set of instructions setting out the specific circumstances in which an individual would:

  • not want certain treatments

  • want a particular treatment to be stopped.


An ADRT can’t be used to refuse any basic care needed to keep the individual comfortable. This includes food, warmth, shelter, offers of food and fluids by mouth, and pain control.

It cannot be used to request that life be brought to an end.

The law pertaining to ADRT varies in diefferent countries of the UK and Republic of Ireland.

Read more about ADRT Directive



The POLST (Portable Medical Orders - formely known as Physicians Orders for Life-Sustaining Treatment) is an out of hospital physician’s order that indicates patient preferences for resuscitation and scope of treatment, intended to be completed for seriously ill or frail patients and to be followed by emergency medical providers.  

The POLST is in wide use in the U.S.A. and comes in several state-specific versions.

The choices for scope of treatment included in a POLST range from full treatment to comfort-focused measures, and in the latest POLST revision, patients can also list their preferences for artificial nutrition.

To be valid, the form needs to be signed by a physician and the patient, or the patient’s legally recognized decision maker.

Read more about POLST

DNACPR Directive


A Directive Not to Attempt Cardio-Pulmonary Resuscitation is often a significant aspect of advance care, where a person may decide that they do not want resuscitation attempted in the event of, for example, sudden cardiac arrest.  

Joint guidance ‘Decisions Relating to Cardiopulmonary Resuscitation’ was published in 2014 by the British Medical Association, Resuscitation Council (UK) and the Royal College of Nursing.

In 2015 the Resuscitation Council (UK) revised its 2009 model forms and guidance notes for recording DNACPR decisions, to help healthcare workers and organisations to achieve uniformly high standards in recording and communicating decisions about CPR.

Read more about DNACPR Directive

Enduring Power of Attorney (EPA) and Lasting Power of Attorney (LPA)


An Enduring Power of Attorney is a document appointing a person (an ‘Attorney’) to manage the property and financial affairs of another person (the ‘Donor’).

If the Donor becomes unable to make financial decisions, the EPA must be registered before it can be used or, if it is already in use, before it can continue to be used.


LPAs have now replaced EPAs, which only allowed people to appoint Attorneys to make decisions about property and financial matters on their behalf.

The new LPAs give more protection and extra options.

If someone has already made an EPA and still has capacity, they can either replace it with a new Property and Affairs LPA or can keep the existing EPA.

Read more about the Enduring Power of Attorney



A will or testament is a legal declaration by which a person, the testator, names one or more persons to manage his or her estate and provides for the distribution of his property at death.

Read more about the Will

doctor and patient

Advance Care Planning is one of 8 domains of the

Comprehensive Geriatric Assessment (CGA)

Back To : Comprehensive Geriatric Assessment

tough issues

Discussing Tough Issues

Go To : Discussing Tough Issues

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