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Advance care planning by phone or video

This framework has been designed to support GPs to have advance care planning conversations with patients by phone or video.

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This framework has been designed to support GPs to have advance care planning conversations with patients by phone or video, in the context of COVID-19. It is a tool to help you have honest and open conversations. It is not a script.

You can use existing appointments or touchpoints, such as wellbeing calls, as an opportunity to initiate advance care planning conversations. Sections in italics offer ways to start conversations and ask questions about your patient’s wishes. You can use some or all of them, or you may wish to use your own words

Starting the conversation

Explain why you are calling

Understanding what matters to the person

Explaining treatments

This section provides information to explain what different treatments involve, and how likely they are to be beneficial. Please consider factors such as the person’s pre-existing health conditions and/or frailty, and local guidance when having conversations about treatment options. This will help ensure that the information given is accurate and appropriate for that person as an individual.

If someone wants to refuse critical care or you believe that critical care might do more harm than good, you should have a conversation with them about this. If you are unsure about whether critical care is likely to benefit a particular patient, you can talk to secondary care colleagues.

If the person’s individual needs and situation mean they are unlikely to benefit from critical care, framing the conversation as ‘protecting’ them may be useful.


If appropriate and based on an individual conversation about the person’s wishes and needs:

  • I understand that this might be a worrying time for you, but I’d like to talk with you about how we can make sure you’re protected from invasive treatment if you were to get coronavirus.
  • In your situation, this kind of treatment might not work or could leave you with a worse quality of life.
  • Can we talk about your hopes and priorities for your health and care?

Explaining treatments and outcomes in hospital and critical care

The Royal College of Physicians’ critical care guidelines have useful patient-facing information, including what happens in critical care and expected outcomes following critical care.


For any patients at risk of having a cardiac arrest it is important to discuss CPR, explaining what CPR involves and the potential outcomes for that patient. It is important to understand whether a person would want to be resuscitated.

If you believe that CPR is likely to be futile or not in the person’s best interests and you make a decision that CPR should not be attempted, you must explain this to them (or their family if they lack capacity).

You should also record this clinical decision in their medical notes and on any shared care records that exist in your area. More information on how to do this is below.

Recording the patient’s treatment and care preferences

It is important that you follow your local protocol for recording a patient’s preferences and clinical decisions. A range of tools are included below, not all of which are used in every area.

If you are based in London, make sure you record all decisions about your patients’ treatment and care in a Universal Care Plan (UCP) record.

Advance statement

An advance statement includes anything that is important to someone in relation to their health or wellbeing, such
as their daily routine and what is important to their quality of life. Your patient can complete this on their own if they
choose. It should be uploaded to their medical record.

A Universal Care Plan (UCP) – London-based

The Universal Care Plan (UCP) enables people who live in London to have their care and support wishes digitally shared with healthcare professionals across the capital.


ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment. It is a process that creates personalised recommendations for a person’s clinical care and treatment in a future emergency, should they be unable to communicate this themselves.

The ReSPECT plan is created through conversations between a person and their healthcare professional. The resuscitation status of the person is included in this conversation and a decision is made in the context of their broader clinical care. The plan is recorded on a form including their personal priorities for care and agreed clinical recommendations.

A ReSPECT form is a clinical document. It is not legally binding. A person can have a ReSPECT and be “for CPR attempts recommended”.

Recording a decision not to attempt CPR

If someone wants to refuse CPR or you believe that CPR is likely to be futile or not in the person’s best interests you should have a conversation with them about this, making sure you establish a shared understanding of what outcomes are likely if CPR is attempted.

You should

You must always discuss the DNACPR decision with the person (or someone close to them if they lack capacity), unless doing so is likely to cause the patient “physical or psychological harm”.

Recording the patient’s wish to refuse treatment

Advance decision to refuse treatment

An advance decision to refuse treatment (ADRT, also called advance directive or living will) allows a person to write down any treatments they do not want to have in the future, including CPR, in case they later become unable to make or communicate decisions.

It is only used if the person loses capacity to make the treatment decision in question. If it meets certain requirements it is legally binding and healthcare professionals must follow it.

Sharing a completed Advance Decision to Refuse Treatment

You should

The patient should

Giving a trusted person authority to make health decisions

Lasting Power of Attorney for Health and Welfare

Lasting Power for Attorney for Health and Welfare (LPA) allows someone to give a person they trust the legal power to make decisions if they lack capacity to make decisions for themselves.

An LPA must be registered with the Office of the Public Guardian before it can be used. There is a cost involved. They do not need to use a solicitor.

Thank you to the GPs who supported the development of this publication:

  • Dr Nupur Yogarajah
  • Dr Justin Hayes
  • Dr P S Jarrett
  • Dr Jennie Parker

This resource was been developed in response to the needs of our GP partners in light of COVID-19. It will be reviewed regularly, so if you feel it could be improved or adapted to better suit your needs, please get in touch.

Page last reviewed: 13 February 2023
Next review due: 30 June 2023

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