Intended for healthcare professionals


Doctors should discuss advance care planning with dying patients and those with chronic illness, RCP says

BMJ 2009; 338 doi: (Published 24 February 2009) Cite this as: BMJ 2009;338:b803
  1. Clare Dyer
  1. 1BMJ

    Advance care planning should be offered as part of routine clinical practice to patients with long term conditions and those receiving care at the end of life, says guidance from the Royal College of Physicians and eight other professional and patients’ groups.

    Efforts to promote greater choice and autonomy for patients are at the core of current healthcare policy but can be difficult to achieve if individuals lose the capacity to make decisions about treatment, the guidance points out.

    A review of the literature shows that 60% to 90% of people support advance care planning, although only 8% of people in England and Wales have completed any form of advance care planning document. This compares with 10% to 20% in the United States, Canada, Australia, Germany, and Japan.

    The guidance builds on Advance Care Planning: A Guide for Health and Social Care Staff (, which was published in August 2008 as part of the NHS’s end of life care programme. It also follows changes in the legal framework for making treatment decisions for patients who lack capacity to decide for themselves.

    The Mental Capacity Act 2005, which came into force in October 2007, allows patients with full capacity to appoint a proxy to take healthcare decisions on their behalf if they later become incapacitated. It also creates a statutory framework for patients to take advance decisions to refuse treatment.

    The college’s evidence based guidance says that discussions about advance care planning should ideally be initiated in a primary care or outpatients setting, before the patient becomes acutely unwell. Staff should use their professional judgment to gauge the appropriate time, and patients must be told that discussions are voluntary and that they may defer them or decline them altogether.

    The subject should be raised by an appropriately trained professional who has rapport with the patient—who need not be a healthcare professional but could be a social worker or lawyer—supported by a professional with knowledge of the prognosis and the progression of the disease.

    Patients should be told that completing an advance care planning document does not guarantee that their wishes will be carried out but that signing an “advance decision to refuse treatment” document that is valid and that covers the situation at the time will be respected. However, if a patient who has signed an advance decision to refuse treatment document later appoints someone to take healthcare decisions under a lasting power of attorney, the advance decision document covering the same treatment becomes invalid.

    General practices should, as part of annual care reviews, record how many of their patients who have died were offered advance care planning, the guidance says. Medical records should contain a specific section for advance statements, advance decisions to refuse treatment, and resuscitation decisions, and ultimately the documents should be stored on the electronic patient record, with the patient’s consent.

    The groups that drew up the guidelines with the Royal College of Physicians were the Royal College of Psychiatrists, the Royal College of General Practitioners, the Royal College of Nursing, the British Society of Rehabilitation Medicine, the Alzheimer’s Society, the National Society for Palliative Care, Help the Aged, and the British Geriatrics Society.


    Cite this as: BMJ 2009;338:b803

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