GPAtlas🧭 When to initiate advance care planning
Advance care planning (ACP) is a voluntary process of conversation in which a person thinks about, talks about and records what matters to them for their future care.
• Their wishes can then guide decisions if they later lose the capacity to make or express them.
• ACP is not a one-off form but a series of conversations over time.
• The person can change their mind at any point.
ACP is not only for the dying. It should be offered to anyone at risk of losing capacity through:
• A progressive life-limiting illness such as cancer, heart failure, COPD or dementia.
• Advancing frailty and multimorbidity.
• A condition causing fluctuating capacity.
The practical trigger in primary care is the Gold Standards Framework “Surprise Question”: if the answer is “no,” start the conversation.
| Identification trigger | What to look for |
|---|---|
| The Surprise Question | “Would you be surprised if this patient died in the next 12 months?” If no → consider offering ACP and adding to the practice palliative or supportive care register. |
| General indicators of decline | Progressive weight loss, falling performance status, increasing dependence, recurrent unplanned admissions, or a point where “no further active treatment” is appropriate. |
| Specific clinical indicators | Disease-specific markers – advanced cancer, New York Heart Association (NYHA) class IV heart failure, severe/oxygen-dependent COPD, advanced dementia or frailty, end-stage renal or liver disease. |
The three classic illness trajectories help frame timing:
• Rapid, fairly predictable decline (e.g. cancer).
• Erratic decline with acute exacerbations (e.g. organ failure).
• Gradual, prolonged dwindling (e.g. frailty and dementia).
Tools such as the Gold Standards Framework, the Supportive and Palliative Care Indicators Tool (SPICT) or the AMBER care bundle support identification.
Done well, ACP follows the 2022 Universal Principles:
• The person is central.
• Conversations focus on what matters to them.
• Outcomes are agreed by shared decision-making.
• The plan is shareable and reviewable.
• Anyone may speak up if these are not followed.
Source: NICE NG142 · NICE NG108 · Gold Standards Framework · Universal Principles for Advance Care Planning
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