Complex Care Training

National Institute for Health and Care Excellence

Why has Complex Care Become More of an Issue? Multimorbidity is commonplace and is increasing, especially amongst an ageing demographic in the UK Recent projections suggest that amongst people aged over 65, more than 68% of the population will have more than two chronic medical conditions by 2035 The UK has a rapidly ageing population, due to dramatic improvements in life expectancy since the turn of the 20th century and measures such as childhood immunisations, the introduction of universal healthcare and medical advances in treating adult diseases such as heart disease and cancer Rapid technological advances and positive lifestyle changes, including a decline in smoking have seen life expectancy increase further While UK life expectancy has increased, particularly for women, healthy life expectancy has stalled or even decreased in recent years, suggesting although people are living longer this is not necessarily with better health or quality of life  Life expectancy for people with Learning Disability has also been increasing, as has the total number of older individuals with learning disabilities, which will contribute to the requirement for specialised care homes suited to meet complex needs

Growing Need. Complex care is a growing field that seeks to improve health and wellbeing for people with complex health and social needs: The combination of an aging population and increasing complex care needs is expected to lead to a substantial increase in the demand for care home beds, particularly those that can provide specialised nursing and residential care Although the average health of older people is improving, the increase in the proportion of older people still means a substantial increase in the number of individuals requiring care By 2035, the number of adults aged 85 and over who require 24-hour care is expected to reach 446,000, which is twice the current figure This includes individuals with multiple chronic physical and behavioural health conditions who often face many barriers, as well as frail older adults and people with serious illness The growth and development of complex care has contributed to a growing awareness of the interplay between health inequalities, physical and behavioural health and structural and social conditions

What is Complex Care Management? Complex care management involves the co-ordination and oversight of intricate and highly complex care plans for people using services This involves the organisation of medical resources and services to ensure safe and effective delivery of care Care homes approach to complex care management is comprehensive, integrating medical expertise, continuous staff training or updating and regular individual evaluations to guarantee the highest standards of care delivery Effective complex care management involves a co-ordinated holistic approach that encompasses collaboration with medical, social, psychological and environmental factors focusing on delivery of personalised care plans and co-ordination between health care professionals and community resources

How does Complex Care Differ from Other Types of Care? Complex care services are vital to ensure that people with complex needs receive appropriate and quality care, live safely with optimum wellbeing by providing specialised support, with individuals empowered to live as independently as possible Complex care refers to a specialised, co-ordinated approach designed to meet the multifaceted needs of individuals who have multiple conditions Complex care needs are long-term, progressive conditions, illnesses or injuries and seeks to improve health and well-being for people with complex health and social needs by coordinating bespoke care delivery Complex care differs from other types of care by involving a higher level of medical intervention, often for chronic or long-term conditions and requiring access to specialised, 24/7 support While domiciliary or home care may support peoples with daily activities and general care, complex care delivery involves a more intricate understanding of complex health conditions and medication management

Complex Care Needs. Complex care needs generally fall into one of four overarching broad categories however, many people will have needs across more than one area, which will fluctuate These can very broadly be broken down into the following complex need areas: physical needs mental health needs behavioural needs communication needs The focus is on providing safe care and treatment, minimising symptoms, promoting independence and maximising choice and control, irrespective of the complex condition/s and need/s the person presents.

Common Complex Care Conditions Neurological conditions Multiple sclerosis (MS) Parkinson’s disease Motor neurone disease (MND) Cerebral palsy Epilepsy Traumatic brain injury or acquired brain injury Stroke Muscular dystrophy Genetic and rare conditions Cystic fibrosis Huntington’s disease Ehlers-danlos syndrome (EDS) Spinal muscular atrophy (SMA) Sickle cell disease

Mental health and cognitive disorders Dementia, including Alzheimer’s disease Severe learning disabilities Autism spectrum disorder (requiring high-level support) Schizophrenia or severe mental health conditions Complex physical and sensory disabilities Spinal cord injuries Limb loss or amputation with secondary health complications Sensory impairments (eg, dual sensory loss with related challenges) Palliative and end-of-life care Advanced cancer with palliative needs End-stage organ failure (heart, lung, liver)

Physical Complex Care Needs Physical needs are health related needs and arise when someone has a health need that requires specialist care, support or treatment to reduce the risk of their health further deteriorating or to maintain stability Physical impairments and disabilities can present significant barriers and people may be born with the condition, whilst other times they can result from an accident or illness Some examples include: risk of (or actual) pressure ulcers bowel management and stoma care PEG or gastronomy feeding tracheotomy double incontinence immobility or severe mobility needs tracheostomy care and oxygen dependence dysphagia (elevated risk of choking or aspiration) and oral suctioning any condition that is deteriorating rapidly or that fluctuates significantly

Complex Mental Health Needs Many people live with severe and enduring mental health issues, such as: eating disorders obsessive compulsive disorders self-harming behaviours drug and alcohol addictions depression schizophrenia bipolar disorder

Complex Behavioural Needs Behaviour becomes complex when it is frequently challenging, unpredictable, unmanageable or poses a risk of harm to the person or to others Assessing the circumstances and environments where someone experiences difficulties with complex behaviours is crucial for understanding the underlying causes and developing effective support strategies Dealing with complex behaviours in a care home requires a calm, empathetic and proactive approach, focusing on understanding the underlying causes, using person-centred strategies, and creating a supportive environment There is usually a reason for behaviour that challenges, although it may not always be an obvious one It can take time to understand the trigger and may need the involvement of a specialist, such as a clinical psychologist or a speech and language therapists Behaviour support plans should be based on a shared understanding of the reasons for person’s behaviour

Communication Challenges Individual communication needs will vary significantly, meaning personalised communication methods and care that adapts to meet each person’s complex needs and circumstances, examples include the following People with aphasia (due to a stroke, dementia or a brain injury) may require communication aids so they can interact with those around them Depression can significantly impact communication leading to difficulties in expressing thoughts and feelings, understanding others and engaging in social interactions, potentially exacerbating social isolation and hindering treatment adherence Individuals with autism may face various communication challenges, including difficulties with both verbal and nonverbal communication, understanding social cues, and interpreting language nuances and these challenges can manifest in different ways, impacting the person’s ability to express themselves and understand others

Meeting Complex Communication Needs Meeting the complex communication needs of individuals involves recognising communication can take many forms beyond spoken language, using a variety of methods like gestures, signs, pictures and technology and ensuring respectful and effective communication strategies to meet the person’s needs Individualised communication needs should be identified, respected and met as far as practicably possible by the care provider If care staff are unable to meet these needs, it becomes increasingly hard for the service to provide care and support that is person centred or safe Agitation may ensue if an individual cannot make personal needs known or cannot understand what is happening

Speech and Language Therapy People that have extremely specific communication needs that impact on their quality of life should be supported to access a Speech and Language Therapy (SALT) assessment SALT can offer benefits, including improved communication skills, increased confidence, enhanced social interactions, and better academic and social outcomes, addressing challenges in speech sound production, vocabulary, and comprehension A SALT can assess communication needs and develop a communication passport that can then be used by everyone to communicate more effectively A SALT can also work directly with the staff team to help them understand the person’s communication style, develop strategies for effective communication and use any specialist communication equipment they provide

Complex Care: Conditions That Interact  The following represent a few examples of how complex conditions can interact, but is should be remembered there are many conditions which may interrelate and result in increasingly complex care requirements Neurological conditions or mental health conditions, whereby the person having a stroke causes further cognitive impairments, affecting memory, attention (or executive function), consequently leading to or exacerbating existing mental health issues, such as depression or anxiety Physical disabilities and social isolation where physical limitations due to conditions such as spinal cord injury or multiple sclerosis restrict mobility and participation in social activities, leading to feelings of isolation and loneliness, which can further impact mental health and depression Chronic diseases and cardiovascular health where people with diabetes develop cardiovascular diseases such as heart disease, suffer a stroke, or both Learning disabilities and sensory impairments where the person with a learning disability may also have sensory processing difficulties, creating additional needs and challenges requiring specialised support and interventions  Acquired brain injury can lead to communication impairments, affecting the ability to express needs or engage in social interactions, which can lead to frustration and result in behaviour that challenges and mental health issues

Service Delivery Service delivery for individuals with complex care needs should prioritise personalised, 24/7 support, encompassing medical, physical, personal and emotional needs and should be delivered by a team of trained staff, including nurses, care staff and therapists Organising services to be person centred for those with complex care requirements needs an imaginative approach to assessment, flexible processes and freedom to make changes within the setting to support care arrangements as needs change Whatever the complexity of a person’s condition and consequent challenges, care homes strive to ensure everyone is supported by a staff equipped with the most relevant and up-to-date knowledge of their condition and the most appropriate treatments available to them Integral to the fulfilment of optimum care delivery is ensuring each team member has access to a comprehensive training and development programme Ongoing access to a designated key worker with specialist knowledge improves access to and continuity of support for the person with complex needs

Complex Care Training Staff may need to gain advanced skills to manage multiple health problems which include the following: Respiratory care: managing conditions such as COPD, asthma and respiratory failure  Medication administration: safe and accurate administration of medications, including complex regimens and routes of administration  Infection control: preventing and managing infections in vulnerable individuals  Pain management: understanding and managing different types of pain, including chronic pain  Tracheostomy care: providing proper care for individuals with tracheostomies and understanding and managing ventilator settings and care Tube feeding: providing appropriate nutritional support through feeding tubes  Bladder and bowel management: assisting with continence management and addressing bladder and bowel dysfunction  Mental health: understanding the impact of complex conditions affecting mental health and providing appropriate support End-of-life care: providing compassionate and dignified care for individuals nearing the end of their lives

Managing Complex Medication Issues
 In care homes, medication safety management involves robust policies, procedures and staff training to ensure people receive their medications correctly and safely, including proper storage, administration and record-keeping, as well as reporting and learning from error Medication education and providing clear and concise information about medications, their purpose, side effects and how to take them correctly is essential Care staff should only administer medication when this is clearly documented in the care plan and the prescriber’s directions are clear, specific and unambiguous Pharmacists can play a key role in medication management, including identifying and resolving drug therapy problems, providing medication information, and monitoring medication effectiveness, interactions and a good source of advice Utilising technology, such as medication reminders and electronic health records, can improve medication adherence and safety Medication reviews should be undertaken to identify unnecessary or inappropriate medications

Use of Technology to Support Complex Care Technology plays a vital role in supporting complex care, enabling personalised, proactive and preventative care through tools such as remote monitoring, digital records and AI-powered systems In healthcare, technology can include medical devices; even a handrail is a technology at the simplest level and the more complex end of the scale includes intelligent systems such as “telecare”, linking people’s homes to professional care teams elsewhere, biotechnologies for wound-healing products and self-adjusting bandages that can automatically alter their tension Although we often think of technology in only its narrowest form, it is not just about computers, information and communication and technology but anything that helps us do what we want and need to Technologies such as wearables or smart home devices can help remotely monitor individual’s health conditions, track vital signs and detect falls or other emergencies, allowing for timely interventions Eye-gaze technology which enables individuals with limited mobility to interact with devices and communicate using eye movements

Delegated Tasks and Competence A delegated healthcare intervention is described as an activity, generally clinical in nature, where registered healthcare professionals delegate to a competent care worker, who have been provided appropriate training, monitoring and support When delegating tasks in care settings, ensuring staff competence is crucial; this involves verifying training, skills, and understanding of boundaries, while also ensuring the delegated task is within the care worker’s scope of competence and that they understand the circumstances for referring to the person delegating This includes areas such as: physiological observations, blood pressure monitoring, insulin administration, catheter care and wound care According to NHS England, it is the persons responsibility to make sure that delegation does not harm the interests of people in their care The task is within the other person’s scope of competence and they understand the boundaries of their own competence

Enhanced Health in Care Homes The NHS Long Term Plan contained a commitment to roll out the Framework for Enhanced Health in Care Homes (EHCH) across England between 2020 and 2024 In November 2023, the NHS Enhanced Health in Care Homes (EHCH) framework was updated to provide proactive, personalized care for people living in care homes, including those with complex needs and emphasises collaboration between primary care specialists and care home staff People’s care and support needs change and fluctuate and one of the more valuable elements of EHCH is the focus on anticipating care needs, not just at end of life but at all stages of someone’s care By taking that approach, care homes and the wider system can plan for the actions that they would take in the event of those changes in care needs occurring

Recognising Early Signs of Deterioration All care homes should be supported and encouraged to have clear processes to follow once a change in someone is identified, to prevent any further deterioration and avoid escalation of care where possible Recognising signs of deterioration involves observing changes in a person’s physical and mental state, including vital signs, behaviour and overall function, which can indicate a decline in health Providing training to care home staff to help with the implementation of tools to support the identification of deterioration including escalations plans (eg RESTORE2, RESTORE2mini, soft signs, NEWS2) These tools facilitate clear communication about the care worker’s concerns for the person using services and for specific actions to be agreed in relation to the individual’s ongoing care Implementation of a clear escalation route in-hours and out-of-hours for clinical advice and decision-making should be in place, supported by an appropriate treatment escalation plan or through the ReSPECT process, which creates personalised recommendations for care and treatment in a future emergency

Issues Caring for Complex Needs There can be several issues in complex care provision, including the following: Evolving needs: as peoples needs can change rapidly and unpredictably, requiring flexibility and adaptability from care staff There can be a lack of co-ordination between different healthcare providers and social care agencies, leading to fragmented care People with complex needs may face difficulties in accessing specialised services and therapies Inequity in the level of healthcare support available to people with complex needs Care homes often face funding pressures, making it difficult to provide the necessary resources and staffing for complex care  There can be variations in the level of funding available for different types of care and for different people, leading to inequities in care  The cost of specialised equipment and therapies can be a significant financial burden for care homes The demanding nature of complex care can lead to high staff turnover, impacting continuity of care

Funding for Complex Care People with ongoing significant health needs which are complex and/or severe may be eligible to have their care funded via the NHS Continuing Care Scheme Last year, over 160,000 people in the UK were assessed as having an ongoing healthcare need which qualified for NHS continuing healthcare funding, with many of these require ongoing complex care and support To be eligible the person with complex needs would have to be assessed by the local Integrated Care Board If the person is not eligible for NHS Continuing Healthcare funding, the person may also seek funding via their local authority

Complex Care Packages In terms of wellbeing and general health, the following may be considered as part of a complex care package: Establishing and agreeing on clinical care needs Providing healthy, nutritious meals, as well as adaptive aids to help eat independently, or PEG feeding/assisting with feeding where required Respecting and accommodating diverse cultural needs and preferences Mobility: keeping the person stimulated and as active as possible with equipment and technology aids Respiratory Support: Management of breathing difficulties, including oxygen therapy Personal care needs : this can include routine washing, dental care, haircare and other hygiene practices Assisting with any continence aid and maintaining bowel and bladder care Mental health and emotional support: providing companionship and compassionate assistance Community and social engagement: assistance with opportunities to engage in social activities such as visiting family, shopping, or attending appointments as required Undertaking risk assessments, as necessary Evaluating the care provided, ensuring the right care is delivered at the right time so a person’s needs are met Collaborating with other healthcare professionals involved in a person’s care

What is included a Complex Care Plan? A detailed assessment of the persons physical, cultural, mental, emotional and social needs, including their abilities, strengths and preferences  Identifying specific needs such as neurological conditions, mental health issues, learning disabilities or sensory impairments  Assessment of skin integrity and pressure area care needs Assistance with mobility aides to encourage safe moving and handling Defining specific, measurable, achievable, relevant and time-bound (SMART) goals for the individual’s care  Ensuring effective communication and collaboration between all healthcare professionals involved in the person’s care  Medication management with a clear plan for medication administration, including dosages, times, and potential interactions  Personal care needs addressing mobility, personal hygiene and nutrition Mental health support providing appropriate mental health support and counselling, recognising the impact of health conditions on mental well-being Agree methods to ensure effective communication with the individual, their family, and other health care professionals involved in their care Implementing appropriate rehabilitation programs to optimise function and independence  Assessing the living environment to ensure it is safe, comfortable and meets the person’s needs

Advanced Care Plan (ACP)or Advanced Decision to Refuse Treatment (ADRT) Advance care planning (ACP) is a key part of a PCSP Personalised care and support planning and when done well gives people the opportunity to plan their future care It supports a personalised holistic approach through understanding a person’s preferences and gives them confidence that their care and treatment will focus on what matters most to them if, at a future point, they cannot fully participate in decision-making Every person living in a care home should have the opportunity to express their wishes, feelings and values, which may include their wishes and decisions should they be unable to make decisions for themselves ACP covers emergency care and treatment plans (eg the ReSPECT process), and future care preferences at end of life a person’s condition can deteriorate quickly The person, and those close to them should be able to talk about the care they would like in the future before: the decision must be made urgently, their ability to communicate is limited and communication becomes too tiring or is no longer available to the person

Care Planning and Documentation It is the responsibility of the care staff to undertake care as outlined in care plans prioritising the individual’s wishes, values and preferences regarding their care Incorporating cultural needs into complex care involves understanding and respecting diverse beliefs, values, and practices to deliver personalised and equitable care; this includes active listening, cultural competency training and tailoring care plans to individual preferences As people’s condition/s progress, the care plan should be regularly reviewed and adapted to meet evolving needs For a person with complex care needs care plans often use both short-term and long-term methods to deal with swift potential deterioration of their condition/s The overall aim should be to manage symptoms of the person’s condition/s to ensure the person has the best possible quality of life The individual management plan should focus on the actions needed and a care plan for someone with complex care needs may include medication, gentle exercise, assistive devices, emotional support, PEG feeding and other therapies Care staff should ensure all medication is administered as per MAR chart and any side effects reported and documented It is the duty and responsibility of all involved in care delivery to keep clear and accurate records Documenting every assessment has legal implications, demonstrating due consideration and care of the person using services and the rationale for any treatment carried out

Specific Importance of Record Keeping for People with Complex Needs Accurate records are vital to people using care safety and wellbeing Keeping up-to-date and accurate records about each person using care is the best way to not only ensure that the quality of care is being maintained but also consistently improved In care settings, multiple caregivers might work with the same person Without proper communication and documentation, key information can easily be lost between shifts Detailed daily notes provide caregivers with a clear and comprehensive history of the person’s health and behaviour, ensuring that care is consistent Those with complex needs and all their care givers need to be able to update each other quickly and easily on the events of the day Documenting complex care needs ensures continuity, promotes safe and effective care, facilitates communication among healthcare professionals and helps in identifying and addressing potential issues, ultimately improving outcomes They foster better communication between our care teams, families and other healthcare professionals and they keep everyone informed about important information regarding the care being provided Better tracking of a person’s progress or deterioration over time

Who is involved in Complex Care Delivery?
 Complex care is usually provided by a team including healthcare professionals, working collaboratively to ensure people receive efficient, precise and tailored care Healthcare professionals involved in delivering complex care in care homes typically include community nurses, specialist nurses (eg for palliative care, respiratory care or neurological conditions) Allied Health Professionals (AHPs): physiotherapists (for mobility and rehabilitation support), Occupational Therapists (to adapt home environments and promote independence), Speech and Language Therapists (for swallowing or communication needs), Dietitians (to manage nutrition and feeding plans) GPs often provide oversight, prescribing medications and managing ongoing health conditions Clinical pharmacist support medication reviews and management in co-ordination with other care providers Palliative care teams may include a mix of nurses, doctors and support staff specialising in end-of-life care Social care workers provide non-clinical support with day-to-day activities and emotional wellbeing Care co-ordinators may manage the overall care plan, ensuring different professionals work together effectively

Adaptive Aids. Tilt-in-Space Wheelchairs: Designed for users with complex positioning needs, such as the Invacare Rea Clematis Pro, which offers reclining backrests and seat tilting to manage pressure distribution. Standing and Transfer Aids: Devices like the Drive Ablestand or Arjo Huntleigh Sara Stedy help transfer patients between sitting and standing, enabling movement to toilets or chairs. Hoists and Slings: Used for safe transfers between beds and chairs, reducing risk of injury for both patient and carer. Profiling Beds: Specialized beds, often used in home care, allow for adjusting the body position to improve comfort and breathing.

Challenges for the Sector
 An ever-growing number of people with complex care needs are now living in residential care homes and, understandably, staff find it challenging to fully manage their healthcare requirements Whilst care homes can refuse to take people with complex needs if they lack the resources or expertise to provide the necessary care but must have a valid reason and cannot discriminate Where the care home has no registered nursing presence, they are reliant on primary care providers for trained nursing support District nurses provide most of this care for people using services, but as an already stretched resource, and in some areas, caseloads are at breaking point and reduced numbers of DNs this can also pose increased challenges

Challenges for the Sector
 The rising demand for complex care presents significant challenges for the care home sector, including the need for increased funding, as adequate funding is crucial to support the rising costs of providing complex care and ensuring high-quality staff and care delivery  With complex care delivery care settings need to establish a workforce strategy as skilled care staff will enhance the quality-of-care homes are able to provide If a care home lacks the skilled staff needed to deliver complex care, they will need additional training and development or need to seek external support from healthcare professionals As care home staff need to be adequately trained and equipped to provide specialised care for people with complex needs, staff release to attend such training can be an issue   As the sector faces significant staff shortages, this obviously impacts on the ability to meet more complex care needs

Complex Care Quiz 1. Which of the following best defines “complex care”? A. Short-term treatment for a single acute illness. B. Support for individuals with multiple, chronic, and interacting health conditions. C. Routine care provided solely by family members. D. Hospital-based surgery for a minor injury. 2. Why is the need for complex care currently growing in the population? A. Decreasing life expectancy across the globe. B. A decline in the prevalence of long-term conditions. C. An ageing population and medical advancements allowing people to live longer with chronic illnesses. D. A reduction in the complexity of modern diseases. 3. What is a “co-morbidity”? A. The presence of one or more additional conditions co-occurring with a primary condition. B. A condition that is inevitably fatal. C. A disease that only affects children. D. The complete recovery from a chronic illness. 4. How can complex conditions interact with one another? A. They never affect each other. B. One condition may mask the symptoms of another or complicate its treatment. C. They always cancel each other out. D. Interacting conditions always lead to immediate recovery. 5. Which issue is most likely to affect someone living with complex care needs? A. Total independence in all daily tasks. B. Social isolation and reduced quality of life. C. Zero risk of medication errors. D. Consistent ease in navigating the healthcare system. 6. Why is specialist training essential for staff delivering complex care? A. It is a legal requirement but has no impact on safety. B. To ensure staff can manage specific clinical needs like peg-feeding, stoma care, or ventilators safely. C. It allows staff to perform surgeries at home. D. Training is only necessary for management, not frontline staff. 7. In safe practice, what is the primary purpose of a risk assessment? A. To prevent the individual from doing anything they enjoy. B. To identify potential hazards and implement strategies to minimize harm while supporting independence. C. To reduce the cost of the care package. D. To replace the need for a care plan. 8. What is a common medication-related issue in complex care known as “polypharmacy”? A. Using a single pharmacy for all prescriptions. B. The use of multiple medications by a single patient, often increasing the risk of adverse reactions. C. A legal requirement to take at least ten pills a day. D. The process of manufacturing new drugs. 9. What should be done if a patient with complex needs refuses their medication? A. Force them to take it immediately. B. Hide the medication in their food without telling them. C. Respect their right to refuse, document it, and report it to a clinical lead or GP. D. Stop providing all care until they agree to take it. 10. Which technology can best support independent living for a person with complex needs? A. Standard television sets. B. Assistive technology like “eye-gaze” communication devices or fall sensors. C. Manual typewriters. D. Wired landline phones without speakers. 11. Why is person-centred care vital in complex care delivery? A. It focuses on the diagnosis rather than the person. B. It ensures the individual’s preferences, values, and goals lead the care process. C. It is faster to implement than standard care. D. It eliminates the need for professional medical advice. 12. What is the primary purpose of a care plan? A. To provide a static document that never changes. B. To act as a “living document” that outlines specific needs, interventions, and goals for the individual. C. To prove that the person is too ill to live at home. D. To serve as a billing invoice for the local council. 13. Why is documentation key in complex care? A. To create a paper trail for tax purposes only. B. To ensure continuity of care, track changes in health, and provide evidence for clinical decisions. C. To prevent the patient from seeing their own records. D. Because digital records are not allowed. 14. What is a major challenge currently facing the social care sector? A. An oversupply of qualified staff. B. Funding gaps and difficulties in staff recruitment and retention. C. A lack of people needing care services. D. Excessive government funding. 15. What does EHCH stand for in the context of UK health policy? A. Emergency Health Care Hospital. B. Enhanced Health in Care Homes. C. Every Home Care Help. D. Essential Health and Care Hub. 16. What is a core aim of the Enhanced Health in Care Homes (EHCH) model? A. To move all care home residents into hospitals permanently. B. To provide proactive, joined-up support from GPs and multidisciplinary teams to care home residents. C. To reduce the number of staff working in care homes. D. To replace nurses with digital avatars. 17. What is an “Advance Decision to Refuse Treatment” (ADRT)? A. A request for a specific expensive treatment in the future. /B. A legally binding document where a person specifies which treatments they do NOT want if they lose capacity. C. A recommendation made by a doctor against the patient’s will. D. A document used only for organ donation. 18. Why are Advance Care Plans (ACPs) important? A. They allow family members to make all decisions regardless of the patient’s past wishes. B. They help ensure a person’s future care preferences are known and respected if they can no longer communicate. C. They are mandatory for everyone over the age of 21. D. They automatically grant power of attorney to the local council. 19. What role does NICE play in complex care? A. It provides funding directly to patients. B. It produces evidence-based guidelines to improve the quality of health and social care. C. It is a charity that provides frontline carers. D. It manages the payroll for all NHS staff. 20. Which of the following is a key support organisation for complex care? A. The local cinema club. B. The Care Quality Commission (CQC), which regulates and inspects services. C. Any international travel agency. D. The National Lottery.