Advanced Care Planning COVID-19

Guidance notes for completing ‘My COVID-19 Advance Care Plan’

What is a COVID-19 Advance Care Plan?

A page of information developed by you, with your family or friends (or somebody else if you need help). It outlines the decisions you have made about your treatment and the support you need if you develop severe COVID-19 symptoms and need to contact emergency services or be admitted to hospital. In these circumstances you are likely to be separated from people who usually support you or speak on your behalf, or COVID-19 may make you too breathless to speak. This plan is a way to capture and share, in an urgent situation, the advance decisions you have made around the care and treatment you would like.

What information is required for a COVID-19 Advance Care Plan?

You only need to note down brief information about the key things you want
people to know under each question.

Advanced Care Planning - COVID19

Advanced Care Planning - COVID19


Briefly list any underlying health conditions you have.
Let us know a few things about you as a person e.g. things you do when you are well, like drawing and painting or cycling. Or you are a mother of 3 and a grandmother of 5, or whether you are generally very active etc.

Three important things we need to know

This is one of the most important sections as it is a place for you to indicate the preferences you have for treatment if you have COVID-19.

  • If you do not want to be admitted to hospital, please record this in the first box below.
  • You can indicate here if your priority is comfort i.e. managing symptoms, rather than prioritising sustaining your life, which may involve more invasive treatment.
  • Other things to record under this section might be that you usually have low blood pressure or body temperature, (tell us what they are) or that you have a phobia of needles or sickness.
  • Other helpful information would include how you react if you are very stressed.
If you do not want to be admitted to hospital, please let us know in this box.


This is a list of your medication, doses and frequency.
How you take your medication e.g. orally or through a PEG etc.


It may be that you don’t usually use words to speak, or English isn’t your first language and a family member interprets for you. It might be useful to know how you would indicate distress or discomfort if you are unable to speak.

Emergency Contacts

List the names and numbers of people you would like us to contact in an emergency.
Please tell us who knows about your plan and who we can contact about it if we need to.

Before submitting this advance care plan, please make sure you have a copy. We would advise you to print this page for your records.