DementiaRoadmap Wales

Promoting living well with dementia across Wales

Advance care planning

There are a number of things that can be done to plan for care in the future. These are known collectively as 'advance care planning'. Advance Decisions and Advance Statements enable individuals to make decisions about their views, preferences and wishes about future care before they are no longer able to and provide guidance to relatives and others supporting them.

Advance Care Planning is a process of discussion between the individual and those who provide care for them. There are sources of advice and templates on Advance Care Plans. The term ‘Living will’ is sometimes used to refer to Advance Statements.

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  • Spirituality and ageing: implications for the care and support of older peopleJanuary 22 2013This briefing paper published the Institute for Research and Innovation in Social Services explores why our ageing population requires person-centred care and developmental support in order to maximise its chances of ageing well.
  • Mental Capacity Act Code of PracticeNovember 21 2014This guidance published by the Office of the Public Guardian explains to people working with or caring for adults who lack capacity to make decisions for themselves the legal responsibilities that must be considered under the Mental Capacity Act 2005.
  • Tailored resource for carers and care providers on supporting people to live well with dementiaSeptember 16 2015This resource published by the National Institute for Health and Care Excellence (NICE) highlights the key messages from 10 quality statements which form the quality standard for supporting people to live well with dementia and shows what they mean for carers and care providers.
  • Making decisions: who decides when you can’t?April 20 2009This guidance published by the Office of the Public Guardian explains how the Mental Capacity Act 2005 affects anyone who is unable to make some or all decisions for themselves. It provides advice to help people to plan ahead in case they are unable to make and understand decisions in the future.
  • Planning for your future careSeptember 16 2014This guidance published by the National Council for Palliative Care explains advance care planning to the public. It outlines the different options available to people when planning for their end of life care.
  • Making decisions: a guide for people who work in health and social careApril 1 2009This guidance published by the Office of the Public Guardian explains to health and social care workers how the Mental Capacity Act 2005 affects anyone who is unable to make some or all decisions for themselves.
  • The dementia guideFebruary 22 2014This guide produced by the Alzheimer's Society is for anyone who has recently been told they have dementia.
  • QS30: Supporting people to live well with dementiaApril 3 2013This quality standard, published by the National Institute for Health and Care Excellence (NICE), covers the care and support of people with dementia.
  • Gold Standard Framework Prognostic Indicator GuidanceOctober 4 2011This guidance aims to help GPs, clinicians and other professionals in earlier identification of those adult patients nearing the end of their life who may need additional support.
  • Deprivation of Liberty Safeguards (DoLS)March 5 2014This factsheet published by the Alzheimer's Society explains the Deprivation of Liberty Safeguards (DoLS), which are part of the Mental Capacity Act 2005. It also outlines the process for getting authorisation for a deprivation of liberty and how to get it reviewed.
  • Advance decisionsAdvance Directives (also referred to as advance decisions to refuse treatment, ADRTs, or living wills) may be drawn up by any person with capacity to do so who is over the age of 18, to determine what treatment they might receive in the event of them losing capacity to make decisions under the Mental Capacity Act 2005.
  • Commissioning End of Life Care: Act & EarlyJuly 4 2011This guidance published by the National Council for Palliative Care aims to help healthcare commissioners to prioritise early action on end of life care to ensure people’s choices are met and to avoid unnecessary emergency hospital admissions.
  • Advance care planning toolkitOctober 19 2012This toolkit developed by the National End of Life Care Programme (NEoLCP) aims to help care providers approach the advance care planning process with confidence and knowledge.
  • RCGP Commissioning Guidance in End of Life CareMarch 4 2013This guidance offers a logical six-step framework and overview to support GP commissioners to deliver practical improvements in end of life care, aligned with national policy and quality standards.
  • Matters of Life and Death: Helping people to live well until they dieAugust 4 2012This guidance aims to support practitioners to implement the End of Life Care Patient Charter, jointly produced by the Royal College of General Practitioners and the Royal College of Nursing.
  • Treatment and care towards the end of life: good practice in decision makingNovember 4 2010This guidance provides a framework for good practice aimed at doctors when providing treatment and care for patients who are reaching the end of their lives.
  • Mental Capacity Act 2005March 5 2014The Mental Capacity Act 2005 came into force in 2007 and affects all those working in health and social care involved in caring for people over the age of 16 who are unable to make some or all decisions for themselves.
  • NHS Continuing Healthcare and NHS-funded Nursing CareMarch 28 2019NHS Continuing Healthcare  If you have complex health and care needs, the NHS may cover the cost of all your care at home or in a care home, including the services you receive from the local council. This is called continuing healthcare and is funded ...
  • Social Services Support for DementiaEven if you feel you don't need support now, it's a good idea to know what's available and plan ahead. The adult social services department of your local council can help with your personal care and day-to-day activities. The first step is to arrange a needs assessment.
  • Lasting Power of AttorneyAfter a diagnosis of Dementia, it is worth forward planning including setting up Lasting Power of Attorney for both health and financial affairs. 
  • Preparing for a Social Services Care Needs AssessmentTips for people with Dementia on preparing for a social services care needs assessment can be found on the Alzheimers UK website, link below.  http://www.alzheimers.org.uk/get-support/legal-financial/dementia-care-needs-assessment  
  • Advance Care PlanningIf you were to lose the capacity to make decisions about your life today, what are the important things you would like those caring for you to know about you and what you would want to happen? One way of making people aware of your wishes is by a process that is called advance care planning.
  • Caring for someone with dementiaNovember 20 2019Caring for someone with dementia is a comprehensive booklet published by Age UK, whose network includes Age Cymru in Wales.
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