Advance Care Planning (Adults) in Shropshire, Telford & Wrekin
Severn Hospice’s website is hosting this advance care planning resource for healthcare professionals on behalf of the Shropshire, Telford & Wrekin Sustainability and Transformation Partnership (STP).
Shropshire, Telford & Wrekin’s STP brings together health and care organisations across the county to work more closely together to improve outcomes and care for local people, reduce pressures on services and make best use of financial resources.
An Advance Care Plan Task and Finish Group was established under the framework of the STP to develop a whole-system approach to advance care planning, bringing together guidance, good practice and training resources.
As a local health and care system in Shropshire, Telford and Wrekin we have a duty to protect the safety and dignity needs and choices of our patients and their families. This includes giving people the opportunity to discuss and be involved in planning their future care and support.
Advance Care Planning (ACP) is part of normal health and care practice and enables individuals, their families and those who care for them, to talk about what matters to them. It is then documented in a plan which anticipates their future preferences and health priorities should they become unwell or no longer have the capacity to tell others what they would like.
It is up to every individual to decide whether they want an ACP and these conversations can be started and supported by anyone working in our health and care system. Some individuals will choose not to have an ACP however if someone changes their mind in the future it can always be reviewed.
Anyone can have an ACP but these conversations and plans should ideally be in place ahead of any deterioration in health. This sort of planning is really important with more people living longer and more long term illnesses.
To support the people of Shropshire, Telford and Wrekin and anyone who cares for them, if an ACP is asked for or required, we have brought together a framework and toolkit for practitioners, referencing evidence and guidance, training and practical tips.
This framework is for:
- All health and social care practitioners
- Patient advocates
- Health and social care leaders and managers
- Anyone filling in a ReSPECT document
NB This document has been written for health and care staff. Information about ACP written for the general public, in a number of different languages, can be found by clicking on the following link https://www.england.nhs.uk/improvement-hub/publication/planning-for-your-future-care/
We appreciate that Advance Care Planning is an important and often sensitive subject and therefore have developed this guidance to support the development and review of advance care plans for people within the Shropshire, Telford and Wrekin Sustainability and Transformation Partnership (STP) area.
This guidance provides a framework for a system-wide approach and is supported by a suite of documents including background information.
We thank everyone who has contributed with evidence, experience and concern for patient safety and dignity.
This toolkit has been created to support the Advance Care Planning Framework which references evidence and guidelines, training and practical tips, to support the people of Shropshire, Telford and Wrekin and anyone who cares for them, if ACP is asked for or required.
This toolkit should be used alongside the framework. The framework will be reviewed and updated regularly so it is important to make sure you are referring to the most recent version.
To listen to a recording of our local health professionals, along with a member of the Telford Patients First group, talking about Advance Care Planning on BBC Radio Shropshire please click on the following link which will take you to our YouTube channel https://youtu.be/aaxvb2Rglb4
We have pulled together a list of useful information and resources below:
Advance Care Planning:
- Advance Care Plan Masterclass with Dr Kathryn Mannix, the author of the award-winning international best-seller ‘With the End in Mind’, in Shropshire, Telford and Wrekin. To watch the recording please follow this link https://youtu.be/AmhuZ_4qN04 or the presentation can be viewed here ACP presentation from Kathryn Mannix
- Shropshire Community Health NHS Trust: Karen Williams, Manager of The Woodlands Residential Care Home chats about some new services from Shropcom including ACP: https://youtu.be/rKcm0FtDm2I
- Patient stories from Shropshire Community Health NHS Trust: Patient stories
- The RCGP – Joint statement on advance care planning, 1 Apr 2020: Joint statement
- GSF Advance Care Planning guidance: GSF guidance
- GSF video: Advance Care Planning in 5 simple steps
- Advance Care Planning – Planning for your future care: Planning for your future care
- Advance Care Planning NICE Guidance: A quick guide for registered managers of care homes and home care managers
- Leaflet – Planning For Your Future Care
- Patient stories – ACP patient stories
- Advance Care Planning guidance in context of Covid-19 for primary care: Guidance
- The RCP – Ethical dimensions of Covid-19 for front-line staff, 31 Mar 2020: Guidance
- Guidance on social distancing for vulnerable people: Guidance
- Guidance on shielding and protecting people defined on medical grounds as extremely vulnerable from Covid-19: Guidance
- Responding to Covid-19: The ethical framework for adult social care: Ethical Framework
- Covid-19: BGS statement on research for older people durin the Covid-19 pandemic: Statement
- Resus ReSPECT resources including materials, FAQs and learning App: Resus – ReSPECT
- Easy Read Materials for the ReSPECT document and process: ReSPECT Easy Read
End of Life:
- GSF End of Life Care in Primary Care: End of Life in Primary Care
- GSF Factsheet for Paramedics: Factsheet
- NICE End of Life Care for Adults quality standard: NICE guidance
- Dying Matters Preferred Priorities for Care leaflet: Preferred priorities
Severn Hospice resources:
- Severn Hospice GP Information Hub: Healthcare professional information hub
Cardiopulmonary Resuscitation (CPR):
- Dying Matters CPR Patient leaflet A4: CPR patient leaflet
- DNACPR Frequently Asked Questions: FAQs
- Dying Matters DNACPR Patient Leaflet: DNACPR leaflet
- Spectator article by Molly Bartlett, 19 May 2020: There is nothing brave about signing a DNR
Resources for people with learning disabilities:
- Dying Matters resources for people with learning disabilities: LD resources
- Mencap Booklet on grief for people with learning disabilities: Booklet
- Easy Read Materials for the ReSPECT document and process: ReSPECT Resources
- Dying Matters: Preferred Priorities of Care (Accessible Version)
- A Personalised Care Plan – When I Die
- CRUSE Bereavement Support: CRUSE Booklets
- Karnofsky Performance Status Scale: Determines ability of patient to tolerate chemotherapy
- Supportive and Palliative Care Indicators Tool: SPICT
Frequently asked questions about Advance Care Planning: FAQs