My COVID-19 Advance Care Plan (acp) template – 11 May 2020


Publications approval reference: C0485

My COVID-19 Advance Care Plan

Updated 11 May 2020

Guidance and template in the context of coronavirus (COVID- 19)

This guidance is correct at the time of publishing. However, as it is subject to updates, please use any hyperlinks to confirm the information you are disseminating to the public is accurate.

What is a ‘COVID-19 Advance Care Plan’?

It is a page of information written by you, with your family or friends (or somebody else if you need help). It is a place to write down quickly and in one place, the thoughts and wishes you have on the care and support you would like if you develop severe COVID-19 symptoms.

This does not replace any advance care plan or care and support plan you may already have. You may wish to use some of the information in your existing advance care plan to complete this one.

The information you write here can be used when talking with the medical team supporting you and provide information the team might otherwise not be aware of. In the event of you being unable to say your wishes, the information you provide could be useful in helping clinicians to consider your views when making clinical decisions about your ongoing care. To help this happen, you may choose to keep a copy with you and ask those supporting you (such as your GP) to keep a copy in your notes or on your file.

Any emergency contacts listed will be for the medical team to use if they need to speak to someone. The people you list will not be able to make decisions (even if they are your next of kin) unless they already have a legal position to do that, such as a lasting power of attorney (for health and welfare). For more information on creating a lasting power of attorney or the Mental Capacity Act, please visit the GOV.UK website.

COVID-19 Advance Care Plan is not an advance decision (sometimes known as an advance decision to refuse treatment, an ADRT, or a living will) to refuse a specific type of treatment at some time in the future. If you feel strongly about specific future treatments, you should discuss this with a doctor or nurse who knows you well. They will help you to understand how to make sure this is recorded properly and legally.

More information on this, Advance Decisions to Refuse Treatment, and Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) can be found on the NHS website here.

Advance Care Plan Guidance

To help you complete your COVID-19 Advance Care Plan, we have explained what you might like to include in each of the boxes.

My name; NHS number; I like to be known as Basic information about your name, NHS number, and what you like to be known as.
Summary of my health conditions Briefly list any underlying health conditions you have.
Who am I? Let us know a few things about you as a person.
Three important things I want you to know Write any particular wishes and preferences you have here.

You might also like to state here if you have DNACPR, Advance Decision to Refuse Treatment, or lasting power of attorney – and where a copy is kept.

Medication I take A list of your medication, the doses and frequency.
How my medication is administered How you take your medication, eg orally, through a PEG, etc.
How I communicate It may be that you don’t usually use words to speak; or English isn’t your first language, and a family member interprets for you.

It might be useful to know how you would indicate distress or discomfort if you are unable to speak.

My emergency contacts List the names and numbers of people you would like us to contact in an emergency, to keep them informed of your condition.

Planning my care during COVID-19

My name: NHS number:
I like to be known as:
Summary of my health condition(s) …
Who am I? Something about me as a person …
Three important things I want you to know …
Medication I take …
How my medication is administered…
How I communicate …
My emergency contacts
Who has a copy of this?
1 Name: 2 Name:
Relationship to me: Relationship to me:
Telephone number: Telephone number: