Comprehensive Geriatric Assessment (CGA): Future wishes

A diagnosis of frailty and the completion of CGA does not mean that a person is imminently about to die. However, the time spent with people and their loved ones discussing their current issues, needs and support required to live well with frailty must also include discussion and anticipation of what future needs may be.

People will approach these conversations differently, and it is vital to be respectful and clear. Many older adults have often already spent much time considering thoughts and feelings about dying, but they may or may not have communicated these to family members or made healthcare or legal plans.

Future wishes are an essential component of CGA, with the aim of encompassing information from all the domains of CGA to pre-empt potential deterioration in each of them, outlining how these should (or should not) be managed in line with the patients’ wishes, and their level of functioning/frailty.

These wishes can be as simple as what future tests would be acceptable for patients (e.g. appropriate for blood tests to look for infection or dehydration, but inappropriate for more invasive investigations such as a colonoscopy). They can also involve more complex decisions such as admission to hospital from home, or even a move from home into 24-hour care and decisions involving long term artificial nutrition options.

Documentation of these conversations and decisions is vital, and must be visible to all health, care and emergency professionals, as well as loved ones so they can be enacted as the person wishes when appropriate.

On primary care and community systems, there may be templates such as Future Planning¹ which enable parts of these discussions to be documented by various health professionals, and decisions about admission, ceiling of care etc to be uploaded to shared records such as the summary care record for paramedic staff to access in a crisis.

The following are other forms of documentation which can be used to communicate these decisions.

Lasting Power of Attorney (LPA)

There may come a time in a person’s journey when they do not have the mental capacity to take part in complex decisions about their health and finances. 

In England and Wales, an LPA is a legal document which must be set up (when a person has the mental capacity to do so) via the Office of The Public Guardian. 

There are two types of lasting power of attorney:

1. Health and Welfare
2. Property and Financial Affairs

They are two separate entities and must be applied for separately – you may have one or both. Currently the cost is £82 each² for England and Wales. The paperwork is largely online, but Age UK and the Alzheimer’s society have digital assistance services to help. 

Forms can be filled out by people themselves, or with the assistance of a solicitor if required. Chosen attorneys must be over 18 and have capacity to act on the behalf of the person and in their best interests should they lose capacity.

In Scotland, residents can apply for a Power of Attorney for Health and Welfare, or Finances, or both. For additional information and procedures for Scotland, see The Office of the Public Guardian (Scotland).

In Northern Ireland, you may appoint an attorney for Finances, known as an enduring power of attorney, but there is no equivalent for Health and Welfare as in the rest of the UK. For more information, see NI Direct Government Services.

Advanced Decision to Refuse Treatment (ADRT)

(also known as a Living Will, or Advance Directives in Scotland)

This is a decision which must be made when a patient has capacity. The intention of the document is to outline refusal of a specific treatment at some point in the future. 

It should outline the specific situations in which a treatment is to be refused. Importantly, these documents cannot be used to request certain treatments, such as Cardiopulmonary Resuscitation. The ADRT needs to be written down and signed by both the patient and a witness. This is particularly important if the treatment being refused is life sustaining. This document is only legally binding if it was made when a person is capacitous and applies to the situation at hand. This will only be used if a person does not have mental capacity.

Recommended Summary Plan for Emergency Care and Treatment (ReSPECT)

ReSPECT forms are currently in use in various places around the country, and were created by the Resuscitation Council. In many Trusts across the UK, they have replaced ‘DNACPR’ (Do Not Attempt Resuscitation) forms which were single sheets of paper with yes/no tick boxes. 

Patients with long-term irreversible conditions (and their healthcare providers) are encouraged to have these conversations early, to empower patients to be at the centre of decisions that are made about their care. The DNACPR decision is a part of this form, but there are other clinical and non-clinical interventions which can be included. The ReSPECT form aims to be a quick summary of a patient's future wishes, with space for information about current legal decisions (e.g. an LPA or ADRT), the patient’s relevant past medical history and information which health care providers new to them in an emergency situation (e.g. an ambulance crew or on call GP) make informed decisions which are appropriate for the patient.

Treatment escalation plans are an essential part of future planning, and guidance and examples are available from various resources, such as Future Planning.org and elearning on Advance Care Planning available on the BGS website.

It is vital that after having these conversations, particularly about ceilings of care or prevention of admissions, these written documents are shared widely across care settings and with patients and carers.

Useful resources

• Power of Attorney – Age UK
• Advance Decisions, Advance Statements and Living Wills (PDF Factsheet) – Age UK
• Advance Decisions – Age UK
• ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) – Resuscitation Council UK