ACP in Edinburgh Care Homes

Anticipatory Care Questionnaire

These resources were developed in Edinburgh to support Anticipatory Care Planning with care home residents and their families/ close friends in a project supported by Marie Curie.

Working with care home staff, family members, residents, local GPs, NHS 24 doctors and other professionals, the team developed a tool (ACQ) to help people think and plan ahead.



Podcast from Dr Mackay (Lead GP, Edinburgh IJB) about the value of Anticipatory Care Planning in care homes


The ACQ (Anticipatory Care Questionnaire) helps residents and their family/ close friends think about what they would like to happen or would not want for the resident if their health were to deteriorate.

The main decision to plan for in advance is whether or not to go to hospital:

  1. Stay in my care home and be cared for in a familiar place.
  2. Think about going to hospital if this will help (ask me and those close to me if you can) and think about a GP or nurse visit to help us decide.
  3. Go to hospital for assessment and possible treatment.

ACQ questions - getting less well:

Three common situations were included in the ACQ:

  1. If you (your relative/friend) had a sudden collapse (such as from a stroke or a heart condition), what would you (your relative/friend) like to happen?
  2. If you (your relative/friend) had a serious infection that was not improving with antibiotic tablets or syrup, what would you (your relative/friend) like to happen?
  3. If you (your relative/friend) were not eating or drinking because they were now very unwell, what would you  (your relative/friend) like to happen?

Anticipatory Care Questionnaire for Care Home Residents

Anticipatory Care Questionnaire for Relatives/ Close Friends

Talking about ACP

Our ACQ ‘discussion guide’ aims to help care home staff start and continue conversations about Anticipatory Care Planning in line with their own level of expertise and confidence.

Talking about ACP in Care Homes – a conversation guide for staff

Staying in my Care Home or Going to Hospital – training video for staff

Let’s Think Ahead – a leaflet for care home residents, their families and friends

Flowcharts/ Supporting documents

Flowcharts can be used to guide staff in using the ACQ when a resident moves into the care home and when there is an episode of deterioration in the person’s health.

SPICT (Supportive & Palliative Care Indicators Tool)

We recommend the SPICT tool to help us identify residents whose health is declining for Anticipatory Care Planning. The SPICT-4ALL version is often used by care home staff, residents, relatives and friends.

Poster presentation

     Download CQ Poster