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NHS Lothian Treatment Escala▯on Plan Guidance Notes Some of the informa▯on contained in this document is also available in a video at:h▯p:// intranet.lothian.scot.nhs.uk/Directory/TreatmentEscala▯onPlans/Pages/How-to-use-a-TEP---the- prac▯cali▯es.aspx 1. Purpose of Treatment Escala▯on Plans – the TEP process 1.1. To help minimise harms due to over-treatment or under-treatment and avoid non-beneficial inves▯ga▯ons and interven▯ons, especially when dealing with a deteriora▯ng pa▯ent. 1.2. To encourage conversa▯ons so that a pa▯ent’s values and priori▯es regarding the goals of treatment are ac▯vely considered, especially if they deteriorate. 1.3. To help ensure that the goals of treatment of the people we are looking a▯er are clearly developed, understood and respected. 1.3 To help ensure con▯nuity of care – especially for on-call staff working out-of-hours 1.4. To avoid moral distress among hospital staff 2. Pa▯ents who should have a TEP on admission - Pa▯ents whose condi▯on is unstable, or who are at risk of deteriora▯on, or at risk of dying. - Severe frailty, or admi▯ed from a nursing home. - Progressive organ failure with / without co-morbidi▯es. - Progressive incurable disease e.g. demen▯a, MND. - Cancer diagnosis (check if prognosis has been documented). - At request of pa▯ent / welfare a▯orney or guardian / nearest rela▯ve. - To con▯nue provisions of exis▯ng ACP / ReSPECT / Key Informa▯on Summary (eKIS) / An▯cipatory Care Plan in ECS Report. 3. Prac▯cal guidelines 3.1. The TEP process may be ini▯ated by trainee doctors or senior charge nurses. A PROVISIONAL TEP can be put in place by trainees (FY2 and above). The existence of a provisional TEP will be highlighted by a yellow icon on the TRAK floor plan or EPR. 1Discussion with more senior clinicians is important and expected. In any event, a senior clinician (4 years’ experience or more / consultant) will require to endorse the TEP as soon as possible a▯er its comple▯on. The consultant carries ul▯mate responsibility for the provisions of a TEP. 3.2 The existence of a pa▯ent’s TEP should be reported at hand-overs and huddles. 3.3. There should be no DNACPR without a TEP. This is a standard of care. A red DNACPR form should s▯ll be completed. The TEP form is not a replacement for the DNACPR form even although reference to CPR is made in the TEP. Similarly, the TEP is not a vehicle for DNACPR orders alone. At the very least the Goals of Treatment and the level of escala▯on should be entered. 3.4. Tips for TRAK 3.4.1. How to find a TEP easily on TRAK. On the floor plan, you can access a pa▯ent’s TEP by clicking on the red / green / yellow icon marked “T”. A red icon with a white “T” means that there is a TEP AND a DNACPR in place. A white icon with a green “T” means that there is a TEP BUT NO DNACPR i.e. CPR = ‘yes’. A yellow icon means that the TEP is in DRAFT format and is awai▯ng endorsement. The other access route is via the Pa▯ent Level EPR toolbar. There are three important tabs: Treatment Escala▯on Plan; Significant Informa▯on; and Ques▯onnaires (All). Accessing “Ques▯onnaires” will lead you to any previous TEP. The tab “Significant Informa▯on” will contain a summary of the current TEP at the top. This will also be copied into the tab labelled Clinical Notes. This TEP summary should be cut and pasted into a Discharge Le▯er (\IDL) 3.5. Once opened, look at the date at the top of the TEP pro forma on TRAK. If the stated date is prior to the present date, then a new TEP needs to be completed and endorsed. A TEP only applies to the current admission and cannot be carried forward to subsequent admissions. 3.6. There may be an exis▯ng ANTICIPATORY CARE PLAN (ACP) based in primary care, such as ReSPECT. Refer to Pallia▯ve Care Register or Key Informa▯on Summary (eKIS). Under “Medica▯on and Immunisa▯on” the ECS Report may include details of the pa▯ent’s exis▯ng An▯cipatory Care Plan at the very end of the Report. Any exis▯ng ACP provisions should be respected and honoured, though its provisions will need to be updated to deal with the pa▯ent’s current situa▯on and perspec▯ves. 3.7. Goals of treatment. A brief summary should outline “what are we trying to achieve” This should be wri▯en free-hand in the appropriate box. Example: “End-stage cardiac disease. Relieve pulmonary oedema with diure▯cs + morphine, but no interven▯on in the event of further MI or arrhythmia. DNACPR. Aim to get home”. 23.8. The drop-down list of interven▯on op▯ons In the Treatment Escala▯on Limita▯on sec▯on, there are 3 op▯ons (full escala▯on / selec▯ve appropriate treatments / comfort + suppor▯ve care). When you click on op▯ons 2 or 3 then further choices become available in a drop-down list with 3 sec▯ons - loca▯on, interven▯ons and treatments and feeding. This is not a “menu” but a prompt. You can choose “yes” or “no” but if you leave a box blank, then in prac▯ce this amounts to a default “yes”. It is possible to choose “selected appropriate treatments” and s▯ll have CPR = yes. For example, this might be relevant in pa▯ents who have had cardiac surgery but for whom certain treatment limita▯ons are appropriate. 3.9. Addi▯onal inves▯ga▯ons, interven▯ons or treatments. Other interven▯ons or procedures that may be either “appropriate or “inappropriate” can be entered. Some examples are given in the adjacent boxes. You can highlight and drag items from the boxes into the blank space marked “Appropriate” or “Inappropriate”. Alterna▯vely, you may choose something that is not listed, and enter it free-hand into the “Appropriate” or “Inappropriate” box. 3.10. Discussion and Understanding These sec▯ons are free hand. They are an important record of the interac▯on with a pa▯ent and family. They have medico-legal importance. The TEP is the preferred place for recording this informa▯on because it is easily accessed. If a fuller note of the Discussion / Understanding has already been wri▯en in the Clinical Notes then state: “Refer to Clinical Notes dated dd/mm/yyyy” 3.11. Reviews and updates.The TEP should be reviewed regularly during an admission especially if the clinical situa▯on changes. Only one TEP ques▯onnaire can be created per admission therefore the exis▯ng TEP should be edited. If you update a TEP in the course of a current admission, you need only type in the desired changes and then press Update. The remainder of the TEP will s▯ll be there, unchanged. Once changes are made and updated, what was present before the changes were made is archived in “Ques▯onnaires”. A new “Significant Informa▯on – Treatment Escala▯on Plan” note will also be automa▯cally generated when you update the TEP. 3.12. \IDL – immediate discharge le▯ers. It is important to provide GPs with details of a TEP. You can cut and paste the summary of the TEP that is found in “Significant Informa▯on” into any “canned text” loca▯on including \IDL. 34. Deciding on Goals of Treatment 4.1 The background CONTEXTshould be ac▯vely considered when determining the GOALS OF TREATMENT. Consider … • Does the pa▯ent have an illness trajectory such that they are likely to be in the last 12 months of life? (Surprise Ques▯on) • A Clinical Frailty Score of ≥6 OR is the pa▯ent a nursing home resident? • Advanced disease: organ failure, neurological disease incl. demen▯a, cancer, mul▯ple co- morbidi▯es? Look at the SPICT link in the TEP. • Refractory abnormal observa▯ons e.g. GCS<5, BP<60 systolic, SaO2<85% in which a diagnosis of dying has been confirmed and documented? Aids to exploring CONTEXT a. The Surprise Ques▯on: “Would you be surprised if this pa▯ent were to be in the last 12 months of life?” The answer to the ques▯on is indica▯ve and not predic▯ve. See: h▯ps://bmcmedicine.biomedcentral.com/ar▯cles/10.1186/s12916-017-0907-4 b. The SPICT tool is helpful in assessing CONTEXT and whether pallia▯ve treatment might be appropriate. See: h▯p://intranet.lothian.scot.nhs.uk/Directory/spsp/SPSP/Deteriora▯ngPa▯ent/Documents/ TEP%20SPICT_April-2019-SPICT%20LINK.pdf c. The Clinical Frailty Scale may be useful in guiding appropriate goals of treatment. Consider: If CFS is 5 or more, then the outcomes of many major interven▯ons may be significantly poorer than “average”. This can be included in the discussion with the pa▯ent. For pa▯ents of any age with stable long-term disabili▯es (e.g. au▯sm, cerebral palsy) the Clinical Frailty Scale must not be used. See: h▯ps://www.bgs.org.uk/sites/default/files/content/a▯achment/2018-07-05/rockwood_cfs.pdf Grade Category Descrip▯on Grade Category Descrip▯on 3 Managing Ac▯vity limited to 6 Moderately Some problems with well walking frail stairs, bathing, dressing 4 Vulnerable Symptoms limit 7 Severely frail Completely ac▯vi▯es dependent for personal care 5 Mildly frail Needs help with 8 Very severely Approaching end-of- some ADLs frail life in days or weeks 44.2. REVERSIBILITY. The reason for admission may be something that is in itself reversible. However, whether it is desirable to make the a▯empt needs to be evaluated. For example, a pa▯ent with lung cancer may have hypercalcaemia or a bronchopneumonia, but the acute condi▯on may be an end-of- life event. Interven▯on may serve the pa▯ent’s wishes to “buy ▯me” or alterna▯vely may prolong the dying process and add to a pa▯ent’s suffering. Some▯mes trea▯ng a reversible process is explicitly contrary the pa▯ent’ wishes. 4.3. The CONSEQUENCES of any interven▯on or escala▯on also need to be considered when determining the GOALS OF TREATMENT. The consequences are not necessarily short-term. This includes fu▯lity and harms. Some▯mes short-term gains lead to long-term consequences that are detrimental frankly harmful or that the pa▯ent may not want. Example: 34% of people discharged from Cri▯cal Care a▯er mechanical ven▯la▯on have impaired cogni▯ve func▯on for 6 months or longer and as a result lose independent living. Long-term outcomes may influence whether the pa▯ent wishes treatment to be escalated or not. 5. TREATMENT ESCALATION / LIMITATION CHOICES: 5.1 See sec▯on 3.7 5.2 APPROPRIATE / INAPPROPRIATE TREATMENTS Pallia▯ve treatments may be needed immediately on admission. Palli▯ve treatments should not be delayed and can be given along with rather than as an alterna▯ve to, other interven▯ons. If pallia▯ve surgery (e.g. repair of #NOF) is being considered in a pa▯ent with Frailty Score ≥6 then a TEP to guide the management of poten▯al post-op. complica▯ons is strongly advised such that post- op complica▯ons are treated pallia▯vely where that is appropriate. In this part of the TEP, you should outline anything else that might be APPROPRIATE, or INAPPROPRIATE and contrary to the pa▯ent’s wishes, either now or later in the event of deteriora▯on. 5.3 ESCALATION TO A CRITICAL CARE UNIT. If Cri▯cal Care is to be considered, then early consulta▯on with the Cri▯cal Care consultant is essen▯al. Ideally whether or not the pa▯ent might require to be transferred to Cri▯cal Care in the event of significant future deteriora▯on should be considered at the ▯me of admission or during a ward round. Do not wait un▯l he pa▯ent “crashes” or the Early Warning Score increases. If in doubt, request an early consulta▯on. 56. DISCUSSION and related issues 6.1 DISCUSSION with the pa▯ent (or their family member) is an essen▯al element in se▯ng the goals of treatment and developing a TEP. Explaining the reasons for the illness and how co-exis▯ng condi▯ons / the pa▯ent’s overall health status (e.g. high Frailty Score) affects the choices that are available is the essence of the conversa▯on. 6.2. DECISION-MAKING CAPACITY You should consider whether the pa▯ent has mental capacity to be involved making decisions about their care. Pa▯ents who are physiologically unstable may not be in a posi▯on to fully consider the implica▯ons of their treatments. Remember that in acute illness, loss of decision-making capacity may be temporary and if so, future decision-making should involve the pa▯ent. Refer to Adults with Incapacity (Scotland) Act (2000)). Complete an AWI Sec▯on 47 form if necessary. 6.2. IMPAIRMENT OF DECISION-MAKING CAPACITY does not preclude use of the TEP. In all but excep▯onal circumstances, the goals of treatment are jointly agreed with the pa▯ent and/ or family and/or legally appointed representa▯ve, and should be documented. However, if it is not possible to have the conversa▯on, but it is clear that a par▯cular interven▯on would be harmful now, or later if there is deteriora▯on, or burdensome or contrary to pa▯ent’s known wishes, then a TEP should be put in place. The clinician’s ethical responsibility is to ensure that medical harms are avoided.A TEP should be put in place if there is a poten▯al risk of significant harm bynot having a TEP. 6.3. Discussion with a pa▯ent need not be long, but it does need to be truthful as well as empathe▯c. Ini▯al ques▯ons can be based on the REDMAP ques▯onnaire (See: h▯ps://www.spict.org.uk/wp-content/uploads/2019/04/ACP-Talk_RED-MAP_April2019.pdf). It can be helpful to engage pa▯ents in shared decision-making by outlining the “best case scenario” and the “worst case scenario” in rela▯on to prognosis and possible treatment (See: h▯ps:// www.nejm.org/doi/full/10.1056/NEJMp1704149) and asking the pa▯ent for their opinion. 6.4. A brief record of the discussion and the pa▯ent’s and / or family member’s UNDERSTANDING should be entered into the relevant sec▯on in the TEP on TRAK. Tis is the preferred place. If this has already been documented in the Clinical Notes, either cut and paste your note or state: “Refer to Clinical Notes with the date dd/mm/yyyy”. Be clear so that somehow else can access this informa▯on. 7. MEDICOLEGAL AND ETHICS ISSUES 7.1. The TEP is not a legally binding advanced direc▯ve. Its provisions should be adhered to as far as possible, but there may be circumstances when it is wise to over-rule the provisions of a TEP. In any 6event the TEP should be reviewed and revised regularly during an admission and with changing circumstances. 7.2. WITHDRAWAL OF TREATMENT The TEP does not provide for the withdrawal of any treatment. This requires separate discussion and documenta▯on. 7.3. DNACPR. The medico-legal requirements for a TEP are iden▯cal to those that apply to DNACPR. NHS Lothian medical directors strongly recommend that a DNACPR order should not be completed without a TEP. Discussing DNACPR in isola▯on or prior to discussing other treatment choices is fraught with hazard. A DNACPR without a TEP is associated with a 3-fold increase in pa▯ent harms. 7.4. Discussing MAJOR POTENTIALLY LIFE-SAVING INTERVENTIONS: Medicolegal aspects Major interven▯ons (e.g. surgery to repair AAA, laparotomy, CPR) need to be discussed with the pa▯ent / family if the interven▯on is designated in law to be poten▯ally life-saving, even if the interven▯on is not going to be offered to the pa▯ent. If the treatment is in this category, but is considered fu▯le or contra-indicated, and is not going to be offered, the reasons for not offering this interven▯on s▯ll need to be discussed. This is to comply with the Appeals Court Ruling on the Tracey case (2014). 7.5. PROVISIONAL and ENDORSED TEPs. The provisional TEP has no standing un▯l it is endorsed. TEPs may be created by FY2 doctors (or above) as provisional TEPs. A provisional TEP will be highlighted by a yellow ‘T’ icon on the pa▯ent’s EPR and the Floor on TRAK. The provisional TEP requires to be endorsed at the earliest opportunity by the lead consultant or a senior trainee doctor (4 years’ experience post-registra▯on or more). Professor D Robin Taylor. Last edited May 27 , 2022 7