Palliative Care Wales
I - Identify


Advance Care Planning

Identify appropriate patients for Advance Care Planning (ACP)

Opportunities for Advance Care Planning discussions should be actively sought by all healthcare professionals, working in primary or secondary care.

Advance care planning may be initiated by patient or relative at any time.


Triggers for healthcare professionals to initiate Advance Care Planning may include:

  1. At diagnosis, or shift of treatment focus, in a 'terminal illness' e.g. metastatic cancer, severe COPD, Grade IV heart failure, MND
  2. Multiple hospital admissions
  3. "Would not be surprised if patient died in next 6-12 months"

See End-of-Life Care Indicator Tools for more guidance.

GP Palliative Care Register

In primary care, regular review of patients at the GP Palliative Care meeting is a good opportunity to identify patients for whom ACP is appropriate.

Secondary care

During a hospital admission, especially if the patient is considered unlikely to survive, advance care planning should be undertaken by the secondary care team.

Secondary care also has an important role in identifying patients suitable for advance care planning, which may be best undertaken back in primary care.

This may be at the time of discharge, or in out-patient clinics.

Communication with primary care is essential -

Issues to be communicated from secondary to primary care:

  • Identify patients suitable for inclusion on the Palliative Care Register
  • Change in focus of care e.g. curative to palliative, patient decision not to start dialysis
  • Change in expected prognosis group (months, weeks or days cf. Traffic lights)
  • Likely complications e.g. PEG tube for MND, de-activation of ICD