Advance Directive for Care Homes, Hospitals, and Hospice in Scotland

Care Transitions Are Where Advance Directives Get Lost

The riskiest moments for anyone with an advance directive in Scotland are the transitions — admission to a care home, discharge from hospital to home or residential care, and the shift from curative to palliative care. Each transition involves a new care team, new clinical records, and a new setting where the previous team's documentation may not follow automatically.

In Scotland, the NHS Key Information Summary (KIS) provides a centralised digital record that should bridge these gaps. But KIS entries are only as complete as the GP or clinical team made them, and care homes operate outside the NHS — they are regulated by the Care Inspectorate, not NHS Scotland, and do not have direct access to the KIS in the same way hospital staff do.

Understanding how advance directives interact with each care setting is the difference between documented wishes that are followed and documented wishes that sit unread in a file.

Care Home Admission

When a parent or family member is admitted to a residential care home in Scotland, the care home will conduct an initial assessment and create a personal care plan. This is where the advance directive needs to be formally introduced into the new setting.

What to do:

1. Provide a copy of the advance directive to the care home manager at or before admission. Ask for written confirmation that it has been added to the resident's care file.

2. Ask how the care home records advance care preferences. Some homes use their own anticipatory care planning forms; others simply file external documents. Either way, the directive's specific treatment refusals should be recorded in the resident's care plan so that all care staff — not just the manager — know the preferences exist.

3. Confirm GP continuity. If the move to a care home involves registering with a new GP practice, the advance directive needs to be delivered to the new practice and uploaded to the KIS. Ask the new practice to confirm or update the KIS entry.

4. Brief the welfare attorney. If a welfare POA is in place, the attorney should introduce themselves to the care home staff and confirm their contact details are on file. The welfare attorney's authority covers decisions that go beyond routine care.

Hospital Discharge

Hospital discharge planning in Scotland is increasingly fast-paced, and the process frequently catches families off guard. A parent admitted after a fall or acute illness may be discharged to a care home or home with a care package within days, with limited opportunity for family input.

An advance directive shapes this process in two ways:

Treatment decisions during the admission. If the patient lacks capacity and the clinical team is considering interventions — surgery, ventilation, feeding tubes — a valid, clear, and applicable advance directive governs which treatments can and cannot be provided. The welfare attorney (if one exists) handles consent for treatments the directive does not address.

Discharge destination decisions. Where the patient goes after hospital is a welfare decision, not a treatment decision. An advance directive does not directly address care home placement, but it informs the discussion. If the directive expresses preferences about remaining at home versus institutional care, the clinical team and social work are expected to consider those preferences under the AWI Act's Section 1 principles.

What to do:

• Ensure the hospital ward has a copy of the advance directive in the patient's hospital notes (not just the KIS — ward staff may not check the KIS for non-emergency decisions)
• If the patient is being discharged to a new care setting, physically deliver a copy of the directive to that setting
• If a social worker is involved in discharge planning, provide them with a copy and confirm they are aware of the welfare attorney's role

Palliative Care and Hospice

The transition to palliative care — whether in a hospice, at home, or within a care home — is where advance directives become most operationally critical. Palliative care involves ongoing decisions about pain management, symptom control, hydration, and nutrition that may continue for weeks or months.

In Scotland, palliative care services are generally well-integrated with anticipatory care planning. Hospice teams routinely ask about advance directives and ReSPECT forms. But there are practical steps to take:

1. Confirm the hospice has a copy of the directive. Hospice admission involves its own care assessment, and the directive should be part of it from day one.

2. Align the directive with the ReSPECT form. The palliative care team will typically initiate or review a ReSPECT form, which records emergency care preferences. This should mirror the advance directive's treatment refusals. Any inconsistency between the two documents creates confusion in an emergency.

3. Discuss the directive's application to palliative scenarios. Some advance directives are written with acute emergencies in mind and do not clearly address the slow decline of palliative care. If the directive refuses "clinically assisted nutrition and hydration" but was written when the patient was healthy, does it apply when the patient is in a hospice and unable to eat? Clarifying this with the palliative care team — and updating the directive if needed — prevents ambiguity.

Making an Advance Directive for an Elderly Parent

If you are helping a parent create an advance directive — often prompted by a health scare, a care home move, or a progressive diagnosis — the legal requirements are the same as for anyone else. The parent must have decision-making capacity, the document must be specific about treatment refusals, and it must be signed and witnessed.

The additional considerations for elderly parents:

• Capacity confirmation is more important. If the parent has any cognitive concerns, have the GP confirm capacity at the time of signing. This protects the document against future challenge.
• Pair it with a welfare POA. The advance directive covers treatment refusals; the welfare attorney handles care home decisions, daily welfare choices, and treatment consents. For an elderly parent, both are essential.
• Get it on the KIS before a crisis happens. Do not wait for a hospital admission to deliver the document to the GP — by then, the clinical team is making decisions in real time and may not have the document available.

The Scotland Advance Directive Planning Kit includes the care home admission checklist, hospital discharge advocacy steps, and the palliative care alignment guide that ensure documented wishes follow the patient through every care transition.

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