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Advance Care Planning or ACP is defined as a process of voluntary discussion between an individual and their care providers. It is to make clear a person’s wishes in anticipation of any deterioration in the individual’s condition in the future, with attendant loss of capacity to make decisions and/or ability to communicate wishes to others.

An Advance Care Plan (ACP) is a patient held record which documents the patient’s wishes and preferences for future care. The ACP document is of particular relevance if disease progression is likely to result in the patient being unable to express their wishes and preferences for themselves.

Completing an ACP is usually but not necessarily the result of structured discussions between individuals and their care providers it may or may not include discussion with those important to the patient. With the patient’s consent the ACP should be made available for key relevant healthcare professionals to view however, this may not always be the wish of the patient. The existence and whereabouts of the ACP should be known by at least one person other than the patient.

Once completed, the ACP should be regularly reviewed and any changes to the ACP shared with relevant others. This may be members of the patient’s family, GP or health care provider.

With the support of Macmillan Cancer Support Betsi Cadwaladr University Health Board is embarking on a three year project to encourage advance care planning across all care settings North Wales. The final objective of the project to see advance care planning discussions embedded into routine practice particularly for people facing life limiting or chronic disease.

There are many different ACP templates widely available on the internet. Within Betsi Cadwaladr University Health Board a patient held ACP has been developed, tested and approved for use North Wales. ‘My Health, My Care, My Decisions’ is a large but comprehensive document comprised of five parts and an accompanying guide for ACP facilitators. The document can be completed in five stages tackling each section as a stand-alone part or it can be completed in full depending on the wishes of the person it concerns.

For more information please contact: Macmillan BCUHB ACP Project Manager.


My Health

My Care

My Decisions

My Life

My Values

My Future Care