What is Advance Care Planning?

Advance Care Planning (ACP) is the process where a patient discusses and records their wishes, values, and preferences about future medical treatment and care in case they lose capacity later on.

It is especially important for:

Elderly patients
Patients with terminal illnesses
Patients with progressive neurological conditions
Patients with dementia
Patients with severe chronic disease

ACP helps ensure care remains:

Patient-centred
Respectful of autonomy
Ethically appropriate
Consistent with the patient’s values

Advance Care Planning: Quick Summary

ACP allows patients to plan future healthcare decisions.
It becomes important if a patient later loses capacity.
ACP supports autonomy and informed decision-making.
It may include:
- Advance Decisions to Refuse Treatment (ADRT)
- DNACPR decisions
- Preferred place of care
- Lasting Power of Attorney (LPA)
Discussions should involve patients, families, and the MDT.
ACP links heavily to palliative care and ceilings of care.

Why ACP Is Important

Advance care planning is important because patients may eventually become unable to communicate decisions themselves.

Without ACP:

Doctors may not know the patient’s wishes.
Families may disagree.
Patients may receive treatments they would not have wanted.

ACP improves:

Quality of care
Patient dignity
Communication
End-of-life planning
Shared decision-making

It also reduces:

Unnecessary invasive treatment
Emotional distress for relatives
Ethical conflict

Main Components of Advance Care Planning

1. Advance Decision to Refuse Treatment (ADRT)

An ADRT is a legally binding decision made by a patient with capacity to refuse specific treatments in the future.

Examples:

Refusing CPR
Refusing ventilation
Refusing feeding tubes
Refusing chemotherapy

For validity:

Patient must have capacity when making it.
It must clearly state treatments refused.
If refusing life-sustaining treatment, it must usually be written, signed, and witnessed.

Important:
Patients cannot demand treatments — they can only refuse them.

2. DNACPR

DNACPR = “Do Not Attempt Cardiopulmonary Resuscitation”.

This means CPR should not be attempted if the patient’s heart stops.

Reasons may include:

CPR unlikely to work
CPR would cause unnecessary suffering
Patient refuses CPR

Important points:

DNACPR only applies to CPR.
It does NOT mean stopping all treatment.
Patients still receive symptom control, oxygen, antibiotics, fluids etc where appropriate.

3. Lasting Power of Attorney (LPA)

A patient can appoint someone to make health and welfare decisions if they lose capacity.

The attorney may decide:

Medical treatment
Living arrangements
Care decisions

The attorney must:

Act in the patient’s best interests
Follow the patient’s known wishes and values

4. Preferred Place of Care

Patients may express where they would prefer:

To receive care
To die

Examples:

Home
Hospice
Hospital
Care home

This supports dignity and patient-centred care.

ACP and Capacity

Capacity is central to ACP.

A patient must have capacity to:

Create an ADRT
Appoint an LPA
Participate fully in ACP discussions

Under the Mental Capacity Act 2005, capacity means the ability to:

Understand information
Retain information
Weigh information
Communicate a decision

Capacity is:

Decision-specific
Time-specific
Presumed unless proven otherwise

ACP and Medical Ethics

ACP strongly links to the four pillars of medical ethics.

Autonomy

Respecting the patient’s right to make decisions about future care.

Beneficence

Acting in the patient’s best interests.

Non-maleficence

Avoiding harmful or burdensome treatments.

Justice

Using healthcare resources fairly and appropriately.

ACP and Ceilings of Care

ACP often helps establish ceilings of care.

A ceiling of care is the highest level of treatment a patient should receive.

Examples:

Full escalation to ICU
Ward-based care only
Palliative care only

ACP helps guide these decisions before emergencies occur.

ACP in Practice

A 78-year-old patient with advanced COPD discusses future care with their GP and respiratory consultant.

The patient says:

They would not want ICU admission.
They would not want CPR.
Comfort and time with family matter most.

The MDT:

Completes a DNACPR form
Documents ward-based care ceiling
Creates an advance care plan
Involves family in discussions

This ensures future care aligns with the patient’s wishes.

Common Medicine Interview Questions

“What is advance care planning?”

Model structure:

Define ACP
Explain purpose
Mention future loss of capacity
Include examples (ADRT, DNACPR, LPA)

“Why is advance care planning important?”

Key points:

Respects autonomy
Improves patient-centred care
Prevents unwanted treatment
Helps families and healthcare professionals
Improves dignity at end of life

“How does ACP relate to ethics?”

Discuss:

Autonomy
Beneficence
Non-maleficence
Justice

“What would you do if a family disagrees with a patient’s ACP?”

Strong answer:

Prioritise patient wishes if valid and capacitated
Communicate sensitively
Involve senior clinicians/MDT
Consider ethics/legal guidance
Maintain empathy and professionalism

Fifteen MMI Question & Answers

Question 1: “A patient with terminal cancer refuses further chemotherapy and wants comfort care only. How would you approach this?”

Answer

“I would first ensure the patient has capacity to make this decision by checking they can understand, retain, weigh, and communicate information. If they have capacity, I would respect their autonomy even if others disagree with the decision.

I would explore their concerns empathetically and ensure they fully understand the benefits and risks of stopping treatment. I would involve the multidisciplinary team, including palliative care specialists, to optimise symptom control and support quality of life.

I would also communicate clearly and sensitively with family members while maintaining confidentiality and prioritising the patient’s wishes. Ethically, this relates strongly to autonomy, beneficence, and non-maleficence.”

Question2: "Why is advance care planning important?"

Answer:

"Advance care planning allows patients to express their preferences for future healthcare while they still have decision-making capacity. It promotes autonomy, guides clinicians and families when difficult decisions arise, reduces uncertainty, and helps ensure care aligns with the patient's values and goals."

Question 3. When should ACP discussions take place?

Model Answer:

ACP discussions should ideally occur before a health crisis develops. They are particularly important for patients with chronic illnesses, progressive diseases, frailty, or life-limiting conditions. However, ACP can benefit any adult and should be viewed as an ongoing conversation rather than a one-time event.

Question 4. A patient becomes upset during an ACP discussion. What would you do?

Model Answer:

I would acknowledge their emotions and respond empathetically.
"I can see this conversation is difficult for you. Thank you for sharing your feelings."
I would give them time to express their concerns, listen actively, and ask whether they would like to continue the discussion or take a break. The patient's comfort and readiness to engage should guide the conversation.

Question 5. What would you do if a patient refuses to discuss ACP?

Model Answer:

I would respect their decision because patients have the right to decline such discussions.
I would explain the purpose of ACP, ensure they understand the benefits, and let them know they can revisit the conversation in the future if they wish. Respecting autonomy is essential.

Question 6. A patient's family requests all treatments, but the patient previously stated they wanted comfort-focused care. Whose wishes should guide care?

Model Answer:

The patient's wishes should guide care if they were expressed while the patient had capacity.
Patient autonomy is a fundamental ethical principle. I would communicate sensitively with the family, explain the patient's previously stated preferences, and support them through the decision-making process.

Question 7. What ethical principles are involved in ACP?

Model Answer:

The main ethical principles are:

Autonomy – respecting the patient's choices.
Beneficence – acting in the patient's best interests.
Non-maleficence – avoiding harm.
Justice – ensuring fair and equitable care.

ACP primarily supports patient autonomy while helping clinicians provide beneficial and appropriate care.

Question 8. What is decision-making capacity?

Model Answer:

Capacity is the ability to make a specific decision at a specific time.
A patient must be able to:
Understand information relevant to the decision.
Retain that information.
Weigh or use the information.
Communicate their decision.
Capacity should always be presumed unless proven otherwise.

Question 9. How would you explain ACP to a patient?

Model Answer:

"Advance care planning is a way of discussing what is important to you and what kind of care you would want in the future if there came a time when you could not speak for yourself. It helps us understand your wishes so we can provide care that reflects your values."

Question 10. What are the benefits of ACP?

Model Answer:

ACP helps ensure that care is aligned with the patient's wishes, reduces anxiety for patients and families, improves communication between healthcare professionals and patients, and may reduce unwanted or burdensome treatments.

Question 11. What are some barriers to ACP?

Model Answer:

Common barriers include:

Fear of discussing death and dying.
Lack of understanding about ACP.
Cultural or religious concerns.
Time constraints in healthcare settings.
Clinician discomfort with difficult conversations.
Family disagreement.

Overcoming these barriers requires sensitive communication and education.

Question 12. A patient asks, "Are you saying I'm dying?"

Model Answer:

"I understand why you might feel concerned. The purpose of this conversation is not to suggest that death is imminent, but to understand what matters most to you and ensure that your future care reflects your wishes should your health change."

Question 13. What would you do if family members disagree with each other about the patient's care?

Model Answer:

I would listen to everyone's concerns respectfully and focus on the patient's previously expressed wishes, values, and best interests.
If needed, I would involve senior colleagues, ethics services, or mediation to help facilitate discussion while keeping the patient at the centre of decision-making.

Question 14. What is a healthcare proxy or surrogate decision-maker?

Model Answer:

A healthcare proxy is a person chosen by the patient to make healthcare decisions on their behalf if they lose capacity. The role of the proxy is to represent the patient's wishes and values rather than their own preferences.

Question 15. MMI Role-Play Station

Scenario:
An 80-year-old patient with advanced COPD says:

"I don't want to be kept alive on machines."

Strong Response:

"Thank you for telling me that. Could you help me understand what concerns you most about being on machines?"
"What would quality of life mean to you if your health were to worsen?"
"Have you discussed these wishes with your family or anyone you trust to make decisions for you?"
"We can document these preferences so that your healthcare team understands what is important to you."

High-Yield Tips

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