Advance care planning in homecare: a practical guide for care managers

Advance care planning (ACP) is the process by which someone sets out how they would like to be cared for in the future, at a point when they may no longer be able to make or communicate decisions for themselves. For homecare professionals, it's one of the most important but often least-discussed aspects of person-centred care.

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Research commissioned by St Christopher's Hospice found that 70% of UK adults had never heard of an advance care plan, and just 3% had one in place - a striking gap, given that the people receiving domiciliary care are often the most likely to need one. This guide covers what advance care planning involves, the key documents, your role as a homecare provider, and how to document a person's wishes effectively.

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What is advance care planning?

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Advance care planning is a voluntary process of reflection and conversation. It gives someone the opportunity to think about, discuss, and record their wishes for future care and treatment before they reach a point where they lack the mental capacity to make those decisions. Crucially, it's not solely about end-of-life care. NHS England's universal principles for advance care planning are clear that ACP is relevant to anyone who may be at risk of losing capacity - whether through a progressive illness, a degenerative condition, or simply the natural course of ageing.

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In Scotland, the equivalent process is known as Anticipatory Care Planning. In both frameworks, the goal is the same: ensuring that a person's values, preferences, and specific treatment decisions are known and respected, even when they can no longer speak for themselves. For homecare agencies, this is particularly significant. Your team often has the closest and most consistent relationship with the people you support - making you well-placed to notice when a conversation about future wishes might be timely, and to support it sensitively when it happens.

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The key documents in advance care planning

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Not all advance care planning documents carry the same legal weight, and it's important that your team understands the difference. There are four main documents used in the UK.

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An Advance Decision to Refuse Treatment (ADRT) is legally binding under the Mental Capacity Act 2005. It allows someone over the age of 18 with mental capacity to refuse a specific medical treatment - such as resuscitation or mechanical ventilation - for a future time when they may lack that capacity. For an ADRT to be valid, it must be in writing, signed, and witnessed. If it covers life-sustaining treatment, it must include an explicit statement to that effect. An ADRT can't be used to demand a treatment, only to refuse one. Compassion in Dying offers clear guidance and free templates for anyone looking to create one.

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A Lasting Power of Attorney (LPA) for Health and Welfare is a legal document that allows a person (the donor) to appoint one or more trusted individuals (attorneys) to make health and welfare decisions on their behalf if they lose capacity. Crucially, this type of LPA can only be used once the donor has lost mental capacity - it's not a general permission slip. The Office of the Public Guardian oversees the registration of LPAs in England and Wales. If a client has an LPA in place, your care team should know who the named attorney is and how to contact them.

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A ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) plan is not legally binding, but it carries significant clinical weight. It records agreed recommendations for how emergency care should be managed, including whether CPR should be attempted. It's created collaboratively with the person and their clinical team and is particularly important for clients whose condition may deteriorate suddenly.

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An Advance Statement is also non-legally binding, but must be taken into account by any professional making a best interests decision under the Mental Capacity Act. It can cover anything that matters to the person - where they want to be cared for, their dietary preferences, religious or cultural beliefs, who they want involved in their care, and what they most fear. NICE quality standards on decision-making and mental capacity expect care providers to support people in creating and regularly reviewing these plans. Think of an Advance Statement as a record of the person, not just their medical situation.

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Who should have an advance care plan?

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The short answer is: anyone who wishes to plan ahead, particularly those at risk of losing mental capacity. In a homecare context, that includes a significant proportion of the people you support. Clients with dementia, Parkinson's disease, multiple sclerosis, COPD, heart failure, or other progressive conditions are all strong candidates for advance care planning conversations. So are clients who are older and frail, even without a specific diagnosis.

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It's also worth noting that advance care planning is not exclusively a concern for people who are imminently at the end of their life. Someone in their 60s receiving care following a stroke may want to think through their preferences now, while they have full capacity to do so. The earlier the conversation happens, the more time there is to consider and document wishes properly - and the less likely it is to be rushed during a crisis. Skills for Care's end-of-life care guidance notes that frontline care workers are often the first to identify that someone might benefit from these conversations, because of the depth of the relationship they have built over time.

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The homecare provider's role in advance care planning

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It's important to be clear about what your role is, and what it isn't. As a homecare provider, you're not responsible for drawing up or organising a person's advance care plan. That is a process led by the individual themselves, often with input from their GP, district nurse, specialist clinician, or solicitor. Your role is to support and facilitate, not to direct or advise on medical decisions.

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In practice, this means three things. First, creating an environment where people feel comfortable raising these conversations. If a client mentions worries about what will happen to them as their health deteriorates, that is an opening, not something to deflect. Second, knowing when and how to signpost. If a client or family member asks about LPAs or ADRTs, your team should be able to direct them to their GP, to Compassion in Dying's resources, or to a solicitor. Third, ensuring that any documents or wishes already recorded are stored securely, accessible to the care team, and reviewed regularly - because circumstances change and care plans need to reflect that.

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Understanding why policies and procedures matter in domiciliary care is directly relevant here. Having a clear written policy on how your agency handles advance care planning documentation - who is responsible for checking it exists, where it's stored, and how it informs day-to-day care - is a marker of a well-run organisation and one that CQC inspectors will look for.

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How to raise advance care planning conversations sensitively

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Many homecare managers worry about introducing the topic of advance care planning. It can feel intrusive, or as though you are forcing someone to confront unwelcome realities. In practice, most people welcome the opportunity to discuss what they would want - the difficulty is usually that no one has asked.

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A straightforward starting point is to ask a client whether they have ever thought about what they would want their care to look like in the future, or whether they have spoken to their GP about any wishes they have already put in place. You are not conducting a clinical assessment - you're opening a door. If they have an LPA in place, ask if a copy is stored with their care records. The same applies to ADRTs and ReSPECT plans.

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For clients who lack the mental capacity to have this conversation, the discussion should happen with family members or appointed attorneys. If no LPA is in place and the person lacks capacity, decisions about their care will need to be made in their best interests, in line with the Mental Capacity Act 2005 - and your team should understand what that process involves. CQC's regulation on person-centred care is clear that providers are expected to evidence how they support people's rights to make decisions about their own care.

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If you want to build your team's confidence in having these conversations, Marie Curie and the Dying Matters Coalition both offer free, accessible resources designed for care workers - grounded in real scenarios rather than clinical theory.

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Documenting advance care planning information in your homecare business

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Clear documentation is the bridge between a person's stated wishes and the care they actually receive. If a client has an ADRT but no one on the care team knows it exists - or knows where to find it - it might as well not be there. This is where your systems matter as much as your conversations.

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A good digital care management platform should give you a structured way to record advance care planning information alongside all other client data. Birdie's End of Life Assessment is built for exactly this purpose. It provides a structured framework for recording whether a client has an LPA for Health and Welfare, an LPA for Property and Financial Affairs, an ADRT, or a ReSPECT plan in place. It also captures their preferred place of care if their health deteriorates, any treatments they don't want, the people they want present, their religious or cultural beliefs, organ donation preferences, and funeral wishes. This sits within Birdie's broader suite of 25+ structured assessments and is accessible to the care team at the point of care.

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This matters practically. If a client deteriorates suddenly and an emergency service is called, having clear documentation of their wishes — including a completed ADRT or ReSPECT plan - can make the difference between a care response that honours what they wanted and one that does not. Keeping daily care notes and assessment records up to date is not just about good practice - it's a core part of demonstrating to regulators that person-centred care is happening in reality, not just on paper.

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Advance care planning sits at the heart of genuinely person-centred homecare. It's not a box-ticking exercise or a form to be completed at admission - it's an ongoing conversation about what matters most to the people you support, and a commitment to honouring those wishes when it counts most.

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For homecare managers, the practical priorities are clear: ensure your team understands the key documents and their legal standing, create the conditions for sensitive conversations to happen, and have robust systems in place to record and act on what clients tell you. You're not responsible for organising a person's advance care plan - but you're responsible for making sure that, once it exists, it shapes the care you provide.

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If you want to see how Birdie's End of Life Assessment and care planning tools support this in practice, book a demo with the Birdie team or watch the webinar How Birdie helps you master care planning.

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