Advance Care Planning (ACP) or Future Care Planning is about helping people think ahead, explore what is important to them, and ensure their choices are understood and respected. While the concept is simple, the conversations themselves can often feel difficult to start.
Increasingly, we find that the phrase “What matters most to you?” opens the door to more meaningful discussions than the term “Advance Care Planning” itself. It shifts the focus away from forms and processes and back to the person behind the care plan – their relationships, values, and the things that bring comfort and meaning to their life.
At the Gold Standards Framework (GSF), this person-centred approach sits at the heart of everything we do. By identifying people earlier and encouraging proactive conversations about the future, we can better support care that reflects what is important to each individual and avoid decisions being made in times of crisis.
The earlier these conversations begin, the greater the opportunity to understand what is important to someone and ensure future care reflects their wishes.
Why these conversations matter
When people approach the final stages of life, understanding their priorities can make an enormous difference to their experience and to those around them. Care that reflects a person’s values and choices can bring reassurance, dignity, and comfort – not only for the individual, but also for their loved ones and those providing care.
At GSF, we believe that a good outcome is one in which people receive care that aligns with their wishes and where their voice remains central to decision-making.
Evidence consistently shows that when people have the opportunity to discuss and document their preferences, they are more likely to receive care that reflects their choices, while families often feel more prepared and supported.
Starting the conversation
For many health and social care professionals, beginning conversations about future care and the prospect of dying can feel daunting. There is often a fear of saying the wrong thing, causing distress, or taking away hope.
Yet many people are willing – even grateful – to have these discussions when they are approached with sensitivity, honesty, and compassion.
Starting the conversation is often the hardest step. Creating the space, asking a gentle question, and allowing time for reflection can be enough to begin.
It is not about having the perfect words. It is about being willing to listen.
Respecting individual choice
Not everyone will want to talk about the future or openly discuss death, and this must always be respected. Advance Care Planning is a voluntary process and should never be imposed.
However, it is equally important not to avoid these conversations altogether. People’s readiness to engage can change over time, particularly as their health needs evolve. By introducing discussions sensitively and revisiting them when appropriate, we create opportunities for individuals to share their thoughts, concerns, and priorities when they feel ready.
Within the GSF approach, ACP is not viewed as a single conversation. It is an ongoing process of understanding, recording, sharing, and reviewing preferences as circumstances change.
Planning ahead
Many people find it easier to begin by discussing practical matters such as funeral arrangements, where important documents are kept, or how they would like their affairs managed. These conversations can provide reassurance that loved ones will not be left with uncertainty or additional burden.
For many, planning ahead brings peace of mind and creates space for deeper conversations about what matters most towards the end of life.
What matters in the final stage of life?
Yet what is sometimes less explored is what matters during the final weeks, days, and hours of life itself.
Often, it is the seemingly small details that make the greatest difference.
Some people fear being alone at the time of death and simply need reassurance and the presence of familiar people around them. Others may wish to reconnect with someone important in their lives. Some find comfort in listening to a favourite piece of music, being read to from a cherished book, spending time outdoors, or having a beloved pet close by.
These preferences may seem small, but to the individual they can be profoundly important.
When these wishes are known and recorded, care becomes more personal, compassionate, and coordinated. It helps ensure that a person’s voice continues to guide decisions, even if they are no longer able to communicate their wishes themselves.
Better conversations lead to better outcomes
Advance Care Planning is not about predicting the future or removing uncertainty from life or death. It is about reducing fear where we can, improving communication, and ensuring that decisions are informed by the person’s values, priorities, and preferences.
When ACP is embedded into everyday practice, people are more likely to receive care that reflects their wishes, families experience greater reassurance, and care teams are better able to coordinate support and avoid unnecessary crises.
It can also help to:
- Support more personalised and coordinated care
- Reduce uncertainty and distress for families
- Improve communication across teams and care settings
- Encourage proactive rather than reactive decision-making
- Help ensure care is delivered in line with a person’s wishes and priorities
A human conversation
At its heart, Advance Care Planning is not a clinical task. It is a human one.
It asks us to pause, listen, and recognise the individuality of every person we support.
If we return to that simple question – “What matters most to you?” – we are reminded that the answers are rarely complicated. They are deeply personal and often remarkably simple: being comfortable, being heard, being with the people we love, and being treated with dignity and compassion.
When we take the time to understand who a person is and what is important to them, we are better able to provide care that reflects not only their needs, but also the life they have lived and the choices they would want respected.
That is where good care begins.
Supporting Better Advance Care Planning
At GSF, we believe that every person should have the opportunity to talk about what is important to them. Through our quality improvement training and accreditation programmes, and free resources, we support health and social care teams to build confidence in Advance Care Planning and make these conversations part of everyday practice.
Explore our free Advance Care Planning resources and discover how GSF training and accreditation can help your organisation embed person-centred care and improve outcomes for the people it supports: https://www.goldstandardsframework.org.uk/training-accreditation/free-resources-professionals/