Advance care planning in care homes: a manager's guide

An advance care plan sets out what matters to a person about their future care, including at the end of their life: their wishes and preferences, where they'd like to be cared for, their beliefs, and the treatment they would or wouldn't want. In a care home it's best started early, ideally around admission, while the person and their family are settled and can think clearly. It's written with the person wherever possible, with their family and GP involved, and reviewed regularly as their health changes.

I was a registered manager for 15 years, running care homes. This guide is how we did advance care planning in the homes I ran: when to start the conversation, who to involve, what goes in the plan, how to make sure every shift knows it, and how often to review it. After that comes how it fits with DNACPR, ReSPECT, advance decisions and lasting power of attorney, and what CQC looks for.

Start at admission, not at the end

I always found it's best to talk about this at the admission stage.

It's something families haven't really thought about. At admission they're in an easier mindset, a bit more comfortable, and they can make decisions clearly. So that's when we'd talk about how they want their relative cared for, their medications, their wishes and their desires.

You don't want to bring this up later, when the time is near. What we noticed is that families then tend not to make the right decisions. They rush decisions, or they're more emotional, and that's understandable. Every manager has their own opinion on this, but in the homes I managed, raising it in the early stages was always very successful. Then you keep reviewing it as the person's health changes.

Starting early doesn't mean doing it all on day one. Some residents and families need a few conversations, and a person can change their mind at any time while they have capacity. NICE's guidance on end of life care also expects advance care plans to be reviewed at key points, such as after a hospital stay or when the goals of treatment change.

Who's involved

In the homes I ran, we mainly involved the family and the GP. The GP leads on the clinical side: medicines and treatment. The family knows the person best and, in many cases, one of them held a lasting power of attorney.

The legal picture in England and Wales, in brief (this is general information, not legal advice; the law is different in Scotland and Northern Ireland):

The resident comes first. If they have the mental capacity to make decisions about their care, it's their plan. They should be at the centre of the conversation, and they decide who else is involved. NICE's guidance says carers and others important to the person should be involved if the person agrees.
If the resident lacks capacity, decisions are made in their best interests under the Mental Capacity Act 2005. That means taking into account their past and present wishes, feelings, beliefs and values, and consulting their family and the people close to them.
A lasting power of attorney only covers this if it's a health and welfare LPA. That kind can cover medical care, moving into a care home and, if the person gave the attorney that power, life-sustaining treatment. A property and financial affairs LPA doesn't. A health and welfare LPA must be registered with the Office of the Public Guardian before it can be used, and it can only be used once the person can't make the decision themselves. Ask to see the registered LPA and check what it covers, including whether it gives authority over life-sustaining treatment.
A DNACPR decision is a clinical decision, made by the senior clinician (in a care home, usually the GP). The clinician must discuss it with the person unless that would be likely to cause them harm, or, if the person lacks capacity, consult the people close to them where that's practicable. A family can't sign a DNACPR form on someone's behalf, but an attorney under a health and welfare LPA that covers life-sustaining treatment can refuse CPR for the person, in their best interests. Our guide to DNACPR in care homes covers this in detail.

What we put in the plan

We'd sit down with the family and find out about the person:

What do they like?
What were their favourite moments?
What's their favourite music, and what do they really enjoy doing?

We'd also ask: "Have you got any videos with happy memories in them, with music they used to like?"

Having that plan does make the end of someone's life better, because it's a time to be respected. The plan is how the team knows what respect looks like for that one person.

Alongside the personal side, an advance care plan (many homes call it an end of life care plan) usually records:

where the person would like to be cared for, and to die, if they have a preference;
their religious, spiritual and cultural wishes, including any rituals after death;
who they want with them and who to contact, day or night;
treatment they would or wouldn't want, and whether there's an advance decision to refuse treatment;
their DNACPR or ReSPECT status, if a decision has been made;
who holds a health and welfare LPA, if anyone does.

Music at the end of life

Going back to activities, music was the best thing we found. When people were in the later stages of their life, we'd play their music, and calming sounds too: water, nature, sounds of serenity. These things make a huge difference and can really make a big impact on a person's end of life.

That's why the questions about favourite music and happy memories matter so much at admission. By the time someone is at the end of their life, they may not be able to tell you, and the family may be too upset to think of it. If it's already in the plan, staff can just do it.

If you want more on using music and the person's own history day to day, our guide to care home activities covers it.

Making sure every shift knows

In the homes I ran, a new member of staff couldn't go on the floor without first reading the person's whole file. The DNACPR is in the resident's file, so anyone who starts goes through it.

We didn't allocate agency staff to residents with a DNACPR or at the end of their life. We don't know that agency staff member, and they don't know that resident. We only allocated our key staff: experienced people who'd been with us a long time and knew the resident and their family. Our activities coordinator, who also worked as the family liaison, was part of that too.

That was our choice, not a rule. My advice, for this sensitive work, is to allocate your most experienced staff, the people who know the resident best.

Allocation is one half of it. Everyone on shift, including agency and night staff, still needs to know who has a DNACPR decision, because an emergency can happen when the allocated carer isn't in the room. Make it part of every handover, keep the original form where paramedics can find it, and check that a copy of the plan goes with the person if they're admitted to hospital. NICE recommends that people have a copy of their advance care plan wherever they live, or with them if they're admitted to hospital.

How often to review it

We reviewed the plans every 30 days, or sooner if required.

"Sooner" in practice means whenever something changes: a fall, a hospital admission, a new diagnosis, a change in medicines, the person saying something new about their wishes, or a family member raising a question. As someone approaches the end of their life, things can change week to week, so review more often. Record each review with the date and who took part, even when nothing changes. Our article on how often to review a care plan covers reviews in general.

Advance care plans, advance decisions, LPAs and DNACPR: what's the difference?

This is how it works in England and Wales:

Document	What it is	Legally binding?	Who makes it
Advance care plan	The person's wishes and preferences for future care, built up through conversations and reviewed over time	No, but it guides everyone caring for the person	The person, with family and staff where they agree (or, if they lack capacity, the people caring for them, in their best interests)
Advance statement	A written statement of the person's preferences, wishes, beliefs and values about future care	No, but anyone making decisions in their best interests must take it into account	The person, while they have capacity
Advance decision to refuse treatment	A decision to refuse specific treatment in future, if the person later lacks capacity	Yes, if it's valid and applies to the situation. A refusal of life-sustaining treatment must be in writing, signed, witnessed and say it applies even if life is at risk	The person, aged 18 or over, while they have capacity
Health and welfare LPA	Gives one or more attorneys power to make health and care decisions once the person can't	Yes, once registered and when the person lacks capacity	The person, while they have capacity
DNACPR decision	A decision that CPR won't be attempted if the heart or breathing stops. It covers CPR only, not other care	Not in the way an advance decision is. It's a clinical decision, recorded on a form, that staff and paramedics follow	The senior clinician, after discussion with the person or those close to them
ReSPECT form	A summary of personalised recommendations for care and treatment in an emergency, which can include CPR	No	Created through a conversation between the person, their family and their clinicians. It's used in many, but not all, areas of the UK

What CQC looks for

CQC regulates care homes in England. Its quality statement "Planning for the future" (under Responsive) says providers should support people to plan for important life changes, so they have enough time to make informed decisions about their future, including at the end of their life. In practice that means:

people are supported to plan their future care while they have the capacity to do so;
their decisions and what matters to them are carried through in personalised care plans, shared with those who need to know;
people who want to express their wishes about CPR are supported to do so, and can change their mind.

CQC links the statement to Regulation 9 (person-centred care) and Regulation 10 (dignity and respect), and also to Regulation 11 (need for consent). It lists NHS England's Universal Principles for Advance Care Planning as best-practice guidance. NICE's quality standard on end of life care for adults (QS13) says adults approaching the end of their life should have opportunities to discuss advance care planning.

How Kiwi handles this

Kiwi (our product) records each person's DNACPR status on their profile, as Attempt CPR, DNACPR in place, or ReSPECT form in place, and shows it at the top of their profile, next to their allergies. The care plan has an End of life planning section, with space for wishes and preferences, religious requirements, family involvement and advance care planning. The section is switched off until the home turns it on for a person, so it doesn't count against anyone's plan until it's switched on.

If you'd like to see how Kiwi keeps each person's DNACPR status and end of life plan in one place, book a demo.

Frequently asked

What is an advance care plan in a care home?

An advance care plan records what matters to a resident about their future care, including at the end of their life: their wishes, preferences, beliefs and values, where they would like to be cared for, and treatment they would or would not want. It is built up through conversations with the resident and, where they agree, their family and GP, and it is reviewed as their health changes.

When should advance care planning start in a care home?

Ideally around admission, while the resident and their family are settled and can think clearly, rather than when the end of life is near and decisions get rushed or emotional. It doesn't have to be done in one conversation, and the plan should be reviewed regularly and whenever the person's health or wishes change.

Who should be involved in advance care planning?

The resident first, if they have capacity: it's their plan, and they decide who else is involved. Usually that includes their family and their GP. If the resident lacks capacity, in England and Wales decisions are made in their best interests under the Mental Capacity Act 2005, consulting family and the people close to them. If someone holds a registered health and welfare lasting power of attorney, they make the decisions it covers.

Is an advance care plan legally binding?

Not in itself. In England and Wales, an advance care plan and an advance statement are not legally binding, but anyone making decisions in the person's best interests must take them into account. An advance decision to refuse treatment is legally binding if it is valid and applies to the situation, under the Mental Capacity Act 2005. The law is different in Scotland and Northern Ireland.

What is the difference between an advance care plan and a DNACPR?

An advance care plan covers the person's wishes for all of their future care. A DNACPR decision covers one thing only: that CPR won't be attempted if their heart or breathing stops. A DNACPR is a clinical decision made by the senior clinician, usually the GP in a care home, after discussion with the person or those close to them. It can be recorded as part of a wider ReSPECT plan.

How often should an advance care plan be reviewed?

Regularly, and whenever something changes, such as a hospital stay, a new diagnosis or the person expressing new wishes. A monthly review is a sensible routine, with more frequent reviews as someone approaches the end of their life. Record each review, with the date and who took part.

Sources

Sources last checked: 2 November 2026.

Advance care planning in care homes: a former registered manager's guide