From Plan to Practice: Challenges in Implementing Advance Care Planning in Care Home Residents

Advance care planning is a process where patients and their families can discuss and document their wishes and preferences for future care with healthcare professionals.However, the existence of an advance care plan (ACP) does not guarantee its implementation.We present the case of a 98-year-old woman living with severe frailty who developed a diabetic foot infection with dry gangrene, highlighting the challenges in implementing ACP and the gaps between documented care preferences and clinical practice.Despite anACP to avoid hospital admission, the patient was transferred to hospital when her toes developed black discolouration.Shortly afterward, when she deteriorated in the care home, staff again considered hospital transfer, highlighting challenges in implementing ACPs within community settings.This casedemonstratesthe importance of clear escalation plans, effective communication between healthcare providers and care homes, and ongoing support for care home staff in implementing ACPs.