Clinical guidelines on advance care planning, multimorbidity and winter deaths

Clinical guidelines
Date Published:
29 October 2009
Last updated: 
17 October 2016

Advance care planning (including end of life discussions, advance statements and advance decisions to refuse treatment) is being promoted as part of the NHS end of life care strategy. Such discussions require great skill and considerable knowledge if they are to provide patients with real choices. Older people, especially those with cognitive impairment, are particularly vulnerable in this context.

The British Geriatrics Society, in conjunction with the Royal College of Physicians and other stakeholder groups, have prepared evidence based guidelines on advance care planning with special reference to older people. It can be downloaded from this page (pdf). The key recommendations are that discussions should be led sensitively, being aware that many people do not wish to have such discussions thrust upon them, and that the professional leading the discussion has the appropriate knowledge and training to advise the older person.

One specific area of controversy relates to advance care planning is the use of Advance Decisions to Refuse Treatment (ADRTs). Although these decisions will only be used in a minority of people (no more than 10 per cent), they can cause considerable uncertainty for health professionals faced with patients who have lost capacity but have prepared a draft statement.

NICE published, in September 2016, a guideline which covers optimising care for adults with multimorbidity (multiple long-term conditions) by reducing treatment burden (polypharmacy and multiple appointments) and unplanned care. It aims to improve quality of life by promoting shared decisions based on what is important to each person in terms of treatments, health priorities, lifestyle and goals. The guideline sets out which people are most likely to benefit from an approach to care that takes account of multimorbidity, how they can be identified and what the care involves.

The guideline includes recommendations on:

  • Taking account of multimorbidity in tailoring an approach to care.
  • How to identify people who may benefit.
  • How to assess frailty.
  • Principles of an approach to care that takes account of multimorbidity.
  • Delivering the approach to care.

The guideline is intended for healthcare professionals as well as people with multimorbidity, their families and carers.

NICE published in 2015 a guideline on Excess winter deaths associated with cold homes. You can also find the supporting evidence, as well as all the stakeholder comments that were received during consultation and the responses to these comments. NICE also produced an Equality impact assessment to support the guideline. NICE followed up in 2016 with a quality standard: Preventing excess winter deaths and illness associated with cold homes. This quality standard covers preventing excess winter deaths and health problems associated with cold homes. It includes people of all ages, and takes into account that some people are particularly vulnerable to the effects of the cold, such as people with cardiovascular or mental health conditions, young children and older people.

The recommendations in the guideline have been included in a NICE Pathway, which is an online tool that brings together all related NICE guidance and associated products in a set of interactive, topic-based diagrams.

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