Advance Care Planning Checklist for Scotland

Advance Care Planning in Scotland Means More Than One Document

Advance care planning in Scotland is not a single form or a single conversation. It is a set of connected steps — legal documents, NHS clinical records, conversations with family and clinicians, and ongoing reviews — that together ensure your healthcare preferences are documented, accessible, and respected.

The challenge is that these steps are managed by different systems. Your advance directive is a common-law document you create yourself. Your welfare POA is registered with the OPG Scotland. Your clinical preferences sit on the NHS Key Information Summary (KIS). And your ReSPECT or DNACPR form is completed by a clinician. No single organisation ties them all together.

This checklist covers every step, in the order that makes them most effective.

Stage 1: Decide What You Want

Before drafting any document, work through these decisions:

• Which specific treatments do you want to refuse? Consider CPR, mechanical ventilation, clinically assisted nutrition and hydration, dialysis, and antibiotics for life-threatening infection. For each, identify the clinical scenarios where the refusal should apply (persistent vegetative state, advanced dementia, end-stage terminal illness).

• Where do you want to receive end-of-life care? Home, care home, hospice, or hospital. This preference goes into your advance directive's values statement and informs care planning conversations.

• Who should make decisions when you cannot? This is your welfare attorney. Choose someone who understands your wishes, can handle clinical pressure, and lives close enough to be available in an emergency. You can appoint more than one attorney (jointly or severally).

• What are your organ donation preferences? Scotland operates a soft opt-out system under the Human Tissue (Authorisation) (Scotland) Act 2019. If you have strong preferences about donation, document them alongside the advance directive so they are clear.

Stage 2: Draft and Sign the Documents

Advance directive:

• [ ] Draft specific treatment refusals with clinical scenarios
• [ ] Include the sanctity-of-life clause ("I maintain these refusals even if my life is at risk")
• [ ] Add a values statement explaining the reasoning behind your decisions
• [ ] Sign and date the document
• [ ] Have an independent witness sign (not spouse, relative, or named attorney)
• [ ] Consider having your GP witness for capacity confirmation

Welfare Power of Attorney:

• [ ] Choose your welfare attorney (and substitute, if desired)
• [ ] Draft the POA with a solicitor — include a clause cross-referencing the advance directive
• [ ] Obtain the Schedule 1 Certificate of Capacity (signed by the certifier on the same day you sign the POA)
• [ ] Submit to OPG Scotland via EPOAR (electronic) or post — pay the £99 registration fee
• [ ] If urgency exists, submit an expedited registration request with supporting medical evidence

Stage 3: Clinical Integration

This is the stage most people skip, and it is arguably the most important.

• [ ] Deliver a copy of the advance directive to your GP practice
• [ ] Request that the directive be scanned into your electronic patient record
• [ ] Ask for a clinical alert flag on your record
• [ ] Request a KIS upload — your treatment preferences and welfare attorney contact details should be entered into the Key Information Summary so emergency services can access them
• [ ] Confirm the KIS upload has been completed (ask the practice directly)

If appropriate for your medical situation:

• [ ] Discuss a DNACPR or ReSPECT form with your GP or consultant
• [ ] Ensure the ReSPECT form aligns with your advance directive
• [ ] Confirm the ReSPECT/DNACPR status is recorded on the KIS

Stage 4: Tell the Right People

• [ ] Give a copy of the advance directive to your welfare attorney
• [ ] Give copies to your next of kin and any family members who might be present in a crisis
• [ ] Lodge a copy with any hospital consultant you see regularly
• [ ] If you live in a care home, deliver a copy to the care home manager and ask for it to be added to your care plan
• [ ] Consider carrying a wallet card noting the directive exists and where the original is stored

Stage 5: Maintain and Review

An advance directive does not expire, but it needs regular review:

• [ ] Review after any new medical diagnosis
• [ ] Review after any hospitalisation
• [ ] Review when changing GP practice (ask the new practice to confirm or update the KIS entry)
• [ ] Review if you move to a different part of Scotland
• [ ] Review every three to five years as standard practice
• [ ] After any update, re-sign and witness the new version, deliver copies, and ask your GP to update the KIS

The NHS Scotland Framework: Anticipatory Care Planning

NHS Scotland uses the term "anticipatory care planning" (ACP) to describe this process. It is the same concept as advance care planning, rebranded for the Scottish clinical context. If your GP or hospital consultant mentions ACP, they are talking about the same steps — documenting treatment preferences, appointing a proxy decision-maker, and recording preferences on the KIS.

Some NHS health boards have their own ACP templates and processes. These are helpful clinical tools, but they do not replace a formal advance directive. The NHS ACP process typically produces a clinical record; an advance directive is a legal document. You need both.

For printable checklists, the complete drafting templates, and the GP letter that initiates the KIS upload process, the Scotland Advance Directive Planning Kit provides every step in a single, Scotland-specific workflow.

See more Scotland guides →