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So um welcome everyone. Good afternoon and welcome to our webinar. So I'd like to just thank you all for coming along. I can see that people are joining slowly but surely we had over 200 registrations were sitting at 60 for people at the minute. Um And hopefully that's going to continue to increase. Uh My name's Steven Fryer. I'm a critical care consultant up in N H S Grampian and I have been working on treatment escalation plan implementation along with Robin and others up in Aberdeen. Uh This is the second webinar that we have done the second one in our series and it is going to explore the practicality of looking at treatment escalation plans a little bit about advanced care planning. So, a CPS, we're going to look at the doubts and concerns about their use um or previous webinar, I suppose, discuss the Y and the lot of treatment escalation planning and this webinar looks a little bit more at the, how we're going to um look at how this fits in with the deteriorating patient. So the deteriorating patient um identifying the deteriorating patient is a key element of patient safety. But the response we due to the deterioration patient is also very important. So this means managing the clinical uncertainty that goes for this um identifying ahead of time when treatment escalation is appropriate and when it's not in the patient's best interests. So the webinar looks at implementation of Tepes, looks at A CPS and we'll look at DNA CPR including um identifying the situations where this is appropriate. It'll identify the appropriate tool that delivers the best information in that situation to the clinicians. So, a CPS potentially in primary care and tepes in acute emissions and secretary care. Um It look a little bit about the delivering the training and education that is there to enhance their use, looking at tepes and A CPS and combination and interface between the two. Um and then looking at how we can make these tools digital to enhance their use. Um And finally, Robbins going to touch a little bit on how we um and corporate um tips and A CPS into uh the chemical governance processes and the merger morbidity and mortality process as well. When Robin and I first discussed the idea of using um putting together this webinar about the use of tepes. I think we always thought that maybe uh by 30 people would register, our previous webinar had 200 people. And again, we're sitting at like 240. The last time I looked, uh there are 79 people currently watching at the minute. Um And I think whilst it continues to be a continued surprise us about the number of you that are joining. I think it's testament to the feeling that we all have that we need to change how you manage patient's who are deteriorating. Um I think this needs to be a system where the discussion has had earlier where management is not just timely but it's appropriate and where the plan has been considered in the context of the patient's um wider, the wider trajectory of the patient's journey. Um It needs to be a system where it's open to all and there's consistency quality of care and those concepts of realistic medicine with the discussion of the patient, their families and their carers is maintained. I think the main function of tepes is to notice commissions to identify the goals of care rather than just the technical aspects of care and moving away from that fix it medicine that I'm sure Robyn will mention to having a conversation with the patient, their families and carers about what we're aiming to achieve. So that fulfills the goals of realistic medicine and planning for the future as busy conditions, we all know that communication can get lost on call, staff, hospital night, rapid response teams, etcetera can be on familiar with the patient's and this can lead to overtreatment and nonofficial interventions. Um And I think tips in general A CPS and tips, empower the whole team to act to achieve the goals of care of that patient. It supports decision making, reduces that moral distress that arises when there's ambiguity in management plans. And when the team do um what the I think is right, rather than what they think is expected, I think that um does best for the patient and the conditions. So the webinar explores all of these questions will heal from. Experts have been working in energies, Grampian NHS borders NHS, NHS, Lanarkshire and NHS Lothian. So it's, it's gotten wild widespread. Um We will look at the National Digital platform. Um And we will look at respect, we will look at a CPS, we will look at tests and we'll look at how you uh navigate um all these together. Um We aim to exchange ideas with you. So there is a chat um uh button on the on the right hand side and feel peace, feel free to put questions into the chat. Um And I will work my way through them. Um We have created a lot of the questions you submitted whenever you registered. Um uh There is a frequently asked question document that we've added to the catch up content that you can access through the landing page. So feel free to go and look at that and sue has put the landing page. They're in the chat for you to click on if you want to go. Have a look. Um We will take questions at the end of each talk and we will have a panel at the end if everybody presenting. Um, so that we can have more of a discussion. Um There will be a break halfway through comfort break and you go and have coffee for about 10 minutes. We have a number of breakout rooms um that you can go in and chat to your fellow delegates there and um some of the speakers will be in there as well. Um That is more or less the housekeeping. Um I just want to finish by saying one of the reasons we choose Metal um as the host of the webinar is not just they're excellent support that they always give, but there's a mission behind Metal to provide healthcare training for all. So that means that we are providing this catch up content freely accessible to help train um every healthcare professional everywhere that wants to come in and look at it and it's unlimited by where they are, who they know or the resources they have. So it's there. Um Our first speaker who's maybe popped up in your screen already is Professor Robin Taylor. Um Robin is a consultant RisperDAL position um currently working in Lothian Grampian Borders and he's been implementing text in all those areas. He's previously initiated the tech program in N H S Lanarkshire way back in 2016 and onwards. And he's authored a number of paper respond tep implementation um including papers on reduction and harm for interesting tepes, reducing moral distress amongst medical staff and and recent, excellent, a few article on the subject as well. So Robyn is going to be looking at the challenges to implementation and I shall pass over to Robin 2%. Thank you very much um Stephen and thank thank you to you all for participating and joining in. Um uh This is a simple concept but an amazingly complex underlying uh foundation and what I'm going to do, I'm going to try and take the questions and issues that are opposed to me in the training and education exercises that I've been undertaking in various hospitals over these last 23 years and just explore them. This won't be comprehensive. But at the, at the bottom of all this, the concept can be agreed by many, like we can all agree on the need for carbon reduction in uh different ing further climate change, but actually driving it forward, it means behavioral change on the part of individuals. And uh at its core, there's a whole shift in the paradigm of what actually is good medicine and good medicine. By that, I mean, good medicine in particularly a deteriorating patient because you know, and I know that urgency or a sense of unfamiliarity with the patient and so on and so forth. There are the things that make us act and react in a way which drives protocol driven medicine, which may not be appropriate for the patient. And we have shown that the use of tepes reduces harms in that territory. But that's all very well. But when we're actually trying to encourage one another to adopt and attempts the tip process into medical decision making, there are sincere and genuine challenges along the way and I want to address them. So the first is the whole issue of medical uncertainty. Now, uncertainty never goes away. And as clinicians at whatever level you're functioning at, they'll be there. You're you may maybe think, well, there's the issue of the limitations of my competencies. And then when you come to a bedside for a deteriorating patient, there may be inadequate information or an inadequate detail about their background or what's been done by other clinicians in the two or three days prior to your your arrival to deal with the emergency. And then there are these elements that are actually unspoken, their subliminal often that are we, we bring our own temperament to our decision making. And the way I illustrate this is when we turn up at the airport to get, get check in and go for a flight, some of you will turn up 15 minutes before the closing, the gate closes and some of you will turn up to an hour and a half before that and some will be comfortable turning up early. And some say what a waste of time. There's a whole variety of things within us as persons that gen generate differences in how we handle uncertainty. We're never going to change that. When there's uncertainty in the clinical setting, we tend to say, right, uh will not, will not, we'll deal with the present problems, get on top of the present situation. And if things get worse later on, we'll deal with that, we'll cross that bridge when we come to it. And I want to emphasize that there are two planks to the, to the two elements, particularly conversations with patient's, um, uh, that, but from the foundation for a tet, the first is what are we trying to achieve? And the second is what should we be doing if things get, don't, we don't get on top of the situation and things get worse and that's usually not thought about or it's not sufficiently thought about. And there's no plan in place. If you don't think about it, there can't be a plan. And if there's no plan, then there's the uncertainty of what is going to happen when that patient gets worse. So there's not just in a deteriorating, patient responsibility to recognize it, there's the responsibility to respond appropriately. Some people say to me, well, things are uncertain. Therefore, I must do this or I must do that and we'll give the patient the benefit of the doubt even although the intervention is unlikely to be helpful. Well, that's one way of dealing with uncertainty, but it gets us into difficulties, then there are people say, well, we're very uncertain. We can't possibly put a step in place, the treatment escalation plan in place because we can't fill in the detailed bits of a tip. But I'm going to say to you the absence of a plan, whether you're going on holiday or whether you're attending to a deteriorated patient, the the absence of a plan multiplies uncertainty rather than diminishes it. So if we feel okay filling in a tip or completing a tep process with a patient being admitted, I can't think ahead. I'm uncertain about it. I want to say we need to change that. We need to change that even we need to live with uncertainty. And at the same time, try to put in place a reasonable plan. That means that when the deterioration occurs, they will be, the patient will be treated appropriately rather than in a reactive knee jerk fashion. Um The, the knock on effects are significant not in, in staff as well as patient's if we are paralyzed by uncertainty. Um And I've just done a study among the Fy one Fy twos in Edinburgh and they were given five cases to study and then amazingly on 57% of, of the, of the occasions that they had to make a decision, there was a difference in their minds between what was, what was the right thing to do and what was the expected thing to do now, if they had a plan. If they had a tip, then an F Y two or a hospital at night nurse at 11 o'clock at night would be guided and their insecurity wouldn't be driving them to go for protocol driven interventions which may be inappropriate and internal leading to harms. Um Here's a study looking at what happened to a hospital at night. Team are rapid response team decision, the decision making dilemmas and they had 351 call outs, uh sorry, 351 patient's and it more than one call out to some of the patient's 456 decision making events. And you see here that the consultations that resulted in a change to palliative goals of treatment occurred in 28.5% of these. Now it may differ from hospital to hospital, but there's a message there. It shouldn't be the hospital at night team who are deciding on the goals of treatment. It should be the daytime team and they should that who are on the ward round or at an MD tea or admitting the patient. And at that point in time, there's a plan for what happens or may happen or may need to happen during the night. It shouldn't be out of our staff who are making strategic decisions about a patient's management. Then we come to clinicians, you say to me, I've always done this sort of thing. Well, I can accept that I can accept that many of us as senior clinicians have thought the right thoughts. But I want to say the problem is that we haven't communicated it down the line. Um uh senior clinicians, we have a responsibility not just to the well being of patient's, but to our trainees. And this continuity of care is a major issue in the provision of uh in the provision of out of our services. So we may always have done it. But I'm going to suggest we need also not to think the thoughts but put a plan in place so that our sense of uncertainty doesn't get visited on the on the encore staff or on the patient if they deteriorate out of hours, one of the consultants have chatted to in the western in Edinburgh says I really love tapes on a Saturday morning because I come in, I'm on a one in eight roster with my colleagues and they help me to on a Saturday morning to get a feel for what my colleagues have considered to be appropriate in terms of goals of treatment. Um uh When I'm doing the weekend ward rounds. So it's, it's at every level that what we may have done maybe true. Our priorities for a patient, our engagement in conversations may be part of and parcel of our normal daily practice, but it needs to be communicated and that communication needs to be accessible. And then there's the big one. I don't have time for this. Now, this is a difficult one because I recognize that it's not too long ago that I did acute medicine and you could admit 17 or 19 or 21 patient's in the night. But this is time, well spent steps are associated with good outcomes. Admission's to I T you do go down non beneficial interventions and harms, go down, patient's and families complaints go down hospital costs go down. We've demonstrated that in a number of studies, the problem is I as a clinician do not experience the benefits of tips. I don't get a buzz out of it because to a significant extent, the tep prevents and constrains staff from overtreatment. Overtreatment is our problem. Overtreatment is our problem. And if you have a tape that's effective, then you're raining the system in such the overtreatment futile treatment is constrained. There's a different way of doing things, but the rewards are limited and we just have to accept that the reward is knowing that I've been ethically disposed to the well being of patient's to their priorities, their preferences and to appropriate treatments and that should be reward in itself, but it's difficult to feel it. And I acknowledge that when it comes to conversations being lengthy, I just want to commend to you the issue of red map to develop by Kirsty Boyd. Um So the conversation in an acute patient doesn't last for half an hour. I've got, if I get a patient with acute respiratory failure, complicating uh COPD calm. The conversation can go through these steps. I can prepare the patient to say George um your chest is your chest. You're in trouble with this chest of yours at the moment. And he says, I know doctor and then I get them to reflect a little bit on the way that their, their condition has been evolving over months, weeks or months. Then I come to the diagnosis and say, look, you've got no money and that's got the potential to be life threatening if we don't get on top of it and then I get into. So what is it you would like us to be doing? What do you think? I'll do my best to get you stabilized. But what are your thoughts if things take a turn for the worst, what, what would be your priorities? And then that sets the scene for what are the goals of treatment and what to do if things get worse now have robbed through it? And it's not as fast as that, but it doesn't need to be so time consuming as to be burdensome. And there are certain patients for whom this is imperative in order to guarantee good management further down the track, I might get sued. This usually comes from junior staff and they frightened that by not adhering to the protocol and not intervening, they will be criticized perhaps on the ward round or the huddle at the huddle, but, um, sometimes it goes further than that, say there might be litigation or there might be complaints. So, a few months ago, I went to the Chief litigation Officer for NHS Scotland and I spent an hour with him, Michael Stewart and I asked him to, I asked him to go through his sort of database. Is that where he wasn't a formal database? But he said there are almost no cases of litigation associated with conservative treatment. And he examined all the ins and outs of what was the treatment escalation plan on how it was applied. And he said, look, most cases of litigation relate to a deteriorating patient relating to a deterioration are about overtreatment. Often futile treatment and families get upset if there are harms associated with an intervention that's over the top. That's when the trouble, the trouble arises. And so I want to encourage you to, I want to dismiss your fear of using tips or abandoning protocol driven interventions, as you say, well, I'm going to leave myself exposed from a medical legal point of view. And the answer is that is a very, very unlikely, far more likely is that you've taken into consideration the fact that treatment will be non beneficial. You've discussed it with the patient, George, putting you on that machine with the mask on your face. You know, I'm talking about non invasive ventilation. Uh It didn't do you, it didn't help last time you were in, um, what do you think about it now? And, and then he says, well, when we arrive at a consensus that we're not going to do certain things and then that's the territory where we need to feel a little bit more secure. And this is uh, information from the, the, the NHS law office uh, to tell you your security should be assured assured in terms of the fear of litigation. No. Um I want to go into some elements of implementation and this is relatively recent. Should, when we encourage in training and education sessions, we encourage people to participate and to engage with the process and so on. You think, well, some people just won't engage and don't engage. Uh one of the ways that is being developed. Certainly an NHS Lothian at N H S Grampian is the idea that treatment escalation plans and particularly goals of treatment are woven into the morbidity and mortality review process. I think if we had the right questions asked at Eminem Eminem meetings with that and we'll come to that in a moment. I think a reflective process would reinforce the idea. Tips are a good thing, not so much. Well, there's, there's the communication to but the TEP process. So here, here are screenshots from what's now going onto the track system in NHS Lothian. You see was there a treatment plan in place? If no, was there evidence in there is that some degree of escalation planning took place. If no, did the absence of a written adversely affect communication. If yes, was the treat created in a timely fashion? And if yes, what level of treatment escalation was recorded? Active, full escalation, selected treatments or comfort care? That's the, that's the uh that you can re evaluate, you can look at these slides again later on your, you'll be, you'll have access to them. The more important Slade is this one and that's to do with, to do with goals of treatment. It's more subtle and you have to search and into the notes or into the, into the evaluation of the case more deeply. But it's to say we're their explicit or implicit goals of treatment at the time of admission did where the goals appropriate, did they change as things went along? If did they need to change or they were they timely in terms of changing? Often a patient's course and prognosis changes. But people keep bashing a way of doing the same thing and they ought to have changed, changed course. So here we're getting it down to the, the underlying thinking that drives a treatment escalation plan and drives the response to the deteriorating patient when they deteriorated. And when the team responded to the deterioration, did they have the right goals of treatment in mind? Should they have been embedded in the, in the tip a bit more completely and more fully and so on? And so m and M's are a mechanism whereby this the TEP process can be brought to the light into the, into the light as it were. If you're really keen, you can go for a thing called the structure judgment review method. I'm not going to deal with it in detail, but it's the Royal College of Physicians template for M and M's. And you see here, what in this one question, one, was there a problem in in assessment investigation or diagnosis was the problem associated with non beneficial interventions? And did the problem lead to harm? That's the bunch of questions. But there are eight domains and I'll just let you cast your eyes over that. But there are eight domains in which all of the questions on the previous slide are asked. So you might like to have a look if you were doing in depth M and M's, you might like to look at this template. There are other templates around. It's not, there's no one that's uh that's the best as it were, but just in case you don't have one, this is a really helpful way of assessing, where are we doing the right things from the very beginning for this patient? And did we respond to the deteriorations appropriately? Yeah. So just a note on some implementation strategies, some of you in your questions have we asked, is it for all patient's or just patient's with the designated condition? For example, patient's with a fractured neck of femur. Should they all have a tip? That's a, that's a decision for your own locality. But if I just tell you that in Essex, in the Princess Alexandra hospital, they decided after a while that every patient being admitted acutely should have a tip. And in so doing, you avoid the question, who should have a tip and you move him automatically onto the question, what does the tip designate? What does it contain? So, uh I think in an ideal world, everyone should have attempt. Now that means the majority are for full escalation and not a great deal of, of uh work needs to be done arriving at consensus about the goals of treatment. But I do raise the question and that question was raised by many of you prior to the meeting in what you submitted in your registration. Should you have, who should be doing it well, in, in one locality I've been involved with, they're having advanced nurse practitioners who initiate the tips uh simply because they are admitting patient's in that particular unit. I think everyone in the team should be involved, but of course, it needs to be in the tent, needs to be involved. Usually by somebody with four or more years medical experience, you might include uh tips as part of your structured ward round where there's a checklist, you say has the patient got a temp? Have we reviewed it? Uh make sure that your ward clerks are stacking the paper copies into the same area as you've got D N A C P R forms. And that's regularly done. If you've got the opportunity to grow over the next two years to develop an electronic version, then I would encourage you to do so simply because the compliance goes up if it's on track or similar and you're, you're much easier to do audits. And then in one or two places we've run little campaigns. No, D N A C P R without a tep simply because D N A C P R s are not the best starting point for planning for what might, what might might be needed. If the patient deteriorates, I realize that you can't plan for, you can't discuss it with a patient if they've arrested. But the whole discussion about what are we going to, what are the goals of treatment? What to do if things go wrong shouldn't be started? You shouldn't start off with the issue of CPR. It just gets us into trouble. Patient's misunderstand it, families misunderstand it far better to have a discussion about the contents of attempt. So what are the challenges? Then there's uncertainty, giving the patient the benefit of the doubt doesn't solve it for the patient. It solves it only for me as an as an insecure person or decision maker. Tepes reduce uncertainty particularly for on call staff by setting goals of treatment. We give a framework whereby uncertainty is reduced. And this question, what should be done if things get worse? That's the, that's a key element in all of this. That historically, we haven't, we haven't been asking. We need to think ahead. We need to think. Has this patient got the potential for the deterioration? And let's have a plan for that eventuality even although the plan needs to be flexible. Uh And uh and it may need to be changed at the time. Let's have a plan. We need to be aware of harms because harms avoidance is an integral part of tip creation. Uh And the harms come from well, meaning well motivated staff who want to do their best but do the wrong thing. And finally, let's deal with the time pressure issues. I am giving something precious to my patient by giving them seven minutes in which I can arrive at a consensus about the goals of treatment and what to do. If things go wrong, that is, it's not just an ethical responsibility. It's at the heart of good care. You can call it shared decision making. Yes, you can call it realistic medicine. But if I'm in hospital, I'd like somebody to chat to me just for just for a short while and say, here's what's wrong. What are your, what are your thoughts about the situation and what are your thoughts about what we need to be doing? So this my mantra for all of these things, if it comes up is tips, make it easier to do the right thing, the expected thing to do and the right thing to do are often not the same. And that's been demonstrated to us by, by what the work we've done with junior doctors, let's improve the quality of life, not just for our patient's but for our staff as well by engaging in this process. Let's get feedback from them. We are engaged. There are a number of studies underway at the moment including what do patient's think of all this? What do families think of all this and we're developing that as we speak. Um I, I hope some of you have had a good experience with tips. I can understand some of your hesitance is and you're there. I say your reluctance, but I would say there are rewards in this that are really worth having and even as a management level, if I tell you that complaints and, and problems fed back to management, which of course our time consuming and emotionally demanding they go down then if you're a quality improvement person, then you should be laying hold of the tapes process with, with, with eagerness. So thank you very much for listening and I'm open to questions now. Okay. Thank you very much, Robyn. Um There are no questions in the chat just yet if people want to add any, um please do. Um I might kick off with a question for you. Um Just I'm wondering if the chats working, I assume it is. What are the common barriers that you have um, come up with, against, with implementation of, um Tepes? What about the, the common, common things that come across and what have you uh done to overcome the barriers? What have your solutions been? Uh Well, the first of all, there's the practical value if you're doing with paper forms, are they always available? Let's make sure they're available. That's very practical. The second is uh I think a no non consultant staff feel a little bit as hesitant about engaging in the process. I think. Well, I that's above my pay grade. I shouldn't be doing it. We're encouraging everyone to at least make a stab at it. Remember, it has to be endorsed before it's, it can be activated. It has to be endorsed in order for it to become a medical legally active document so you can encouraging uh younger staff to feel secure in, in embarking on the process is part of it. And that I think we need consultants to be creating a permission giving environment and sure there were mistakes, sure they'll be in, in, in experience, but that's two of some of our practical procedures. I remember learning bronchoscopy and it took four or five months before you got up to running speed with the skills. Well, somebody had to be patient with me and therefore being patient with one another, creating a permission giving environment so that an F Y one or an F Y two knows that Doctor Taylor when he's on his ward round will commend the fact that the tape is in place rather than question, it is going to be a very, very soft but critically important dimension. And last day, I think we probably the barrier, the greatest barriers, the time barrier. And at this point in the life of the NHS, I can understand that. But if we don't spend time, we get disasters. If we don't spend time, we get disasters and that's, and the disaster rate goes down if you have a plan in place. So, um, let's, that's defensive medicine ought to mean not doing everything. Defensive medicine ought to mean putting a plan, a plan in place and, and training ourselves as senior clinicians to think this way because it's not, it's not, it doesn't come naturally to us. So they are the barriers. Okay. Um There is, there's a question from Victoria who is asking finishes grandma has a TEP template. Yes, we are rolling that out. Coming to an area near you. Um, uh Paula has asked if, um, there would be, you know, who should be trained to do this, who should have the conversation. So I think this comes into communication. So training for nursing staff that could have the conversation. Um, or do you have resources Robin, I suppose, would you recommend resources about having the discussion? Um and, um, you know, who, who, who should do that, who, who's open to doing that? You've kind of covered a wee bit in your talk. Right. Well, I, I only put up one slide, the red map tool because that's very helpful in the acute setting. If it's a bit more relaxed. In other words, you're not having, uh, you know, you're not in the middle of a ward round and you're not just admitting 17 patient's, then you can spend a little bit more time. Yes, I can provide guidance and, and resources and sue Gibson from Medal will be happy to provide my email address and I'll be happy to give you directions. Um The thing about communication skills is a bit the communication skills I do need to be learned and they don't, they don't come naturally in a deteriorating patient. You and I want to be optimistic. We want to be hopeful. And yet if we're realistic, I have to say to some of our patient's, I'm not sure I can pull you through or we'll do our best, but we may not win. And you see, we need to be learned to be truth. A tuition in truthfulness is part of communication skills because communications is about empathetic engagement. But it's also about the substance of what we communicate to a seriously ill patient and truthfulness were shy of it were squeamish about a financial fact. If we're not truthful, the patient feels isolated they will know, they have an instinct to know when we're not actually being up front with them. So there's all of that communication skills are just as important as clinical decision making skills. Um But you have to learn it and you have to practice it in order to get it right. You won't get it right, first time and you won't get it right. Probably until you've done it 30 or 40 times Another question around uh communication, um, would be, um, what about the patient or the family who don't want to discuss? Or it's Brian's question here. What if patient's, um, uh family's expectations are unsafe or who are not achievable? I either not a candidate for surgery. How do you have that difficult conversation? Well, I'll be honest, that's come that treatment escalation plans are not going to solve that problem. Um, maybe one in 20 or one in 25 patient's or patients', families will be in that category and it, and it is difficult. It's taxing, it wears, it wears you down. However, in terms of being a plan and you're the first of all, having a plan that's offered to you by a senior staff and is contained in attempt. And then you're having to use as at 11 o'clock at night when you call the family in because of a deteriorating patient. It's easier the platform upon which you stand has made much more robust. If there's a plan already there um for those of you who are juniors in all of this, um I have to suggest to you that you have to say you have to pass it up the line if it's really, really challenging and difficult. And even those of us who have been around a long time, find this an immensely problematic territory of life. And I don't need to say that in front of Stephen Fryer because he's in intensive, the intensive ists have this almost every week as part of their work. It's, it's in the territory of communication skills development. But it, but there's no easy answer to that because we live in an environment where families feel they ought to be controlling the situation rather than the medics tips don't solve that. And I'm not setting out to solve it. But I have every sympathy with you in asking the question. I've got two more questions for you. The first question is about, I think hopefully answering Emma's question here, Joan's question in that. How do you engage your colleagues? How do you engage those senior decision makers um better um whether that's consultant level or even higher management. How do you, how do you say look, we think this is good and useful. Well, uh I think I'll have to be honest, I've struggled with it myself. I've engaged when I was in Lanarkshire. I went after two years of trying to introduce tips. I felt as if I was up up against the brick wall over that very reason. So I went around 100 and 69 of them over a period of a year and had a 1 to 1 conversation from a juniors point of view. I think you need to get up your loins and it's and politely but firmly say, look, I think we really need a tip for this patient. And what do you think should be the boundaries and goals of treatment? What are the boundaries? Is it for full escalation or selected appropriate treatments or comfort cares? The future belongs to you as juniors, the future belongs to you. There's a generation of my generation who find this really difficult. And I think if you learn, if you, if you learn to, to stand firm politely, then you'll do the, you'll do, you'll not just do your individual patient's a service, you'll do the NHS service. This is the future, this is the future. And uh and I look to you, I'm agonizing with you when you feel that you're unsupported. Uh but don't lose heart and don't lose your way in terms of your own career development, become the person that you want your consultant to be when it comes to this type of work, this dimension of work and never give up, never give up. I didn't give up in Lanarkshire and I'm still not going to give up even although I have dearly beloved colleagues who give me a difficult time. That's the best I can say. And I have one last question because it's, it's come up and it'll, it'll come up later on. Um, what would you say? Um, the difference between treatment escalation plan uh form there? An A C P so an advanced care plan and uh and respect as an advanced care plan. What do you think the difference between them is and where, where, where do they sit? Um We're going to hear a little bit about this from our next speakers anyway, but just your opinion on it. Well, uh uh first of all, the treatment escalation plan is designed specifically for the hospital environment for acute admission's and it's about planning for the next few days and it's complementary to what you would find in a respect form or an advanced or anticipatory care plan. Um When a patient's out in the community or at an outpatient clinic, I would use respect because it's a good anticipatory care plan, advanced care plan. And I'm planning for weeks and months ahead and I'm getting the principles of select, selecting or versus not selecting certain ways forward with a patient's healthcare. I'm getting these principles woven into a conversation and I'm getting consensus with the patient in the less pressured setting of advanced my for me out respiration, advanced lung disease clinic. For example, when a patient comes into hospital, no matter what plan they have already there, you need to revise it it needs to be up, the circumstances have changed other, otherwise they wouldn't come in. Sometimes the patient's thoughts about what they want for the best have changed. Or sometimes these thoughts changed during the course of an admission and the, the, uh, the treatment escalation plan compliments what's been done by way of advance care planning or, or providing a respect. The two will talk to each other when the patient's admitted or when the patient's discharged, but they're, they're different. I look, put it this way if I want to climb amount and I wear boots, if I want to walk on the beach, I wear sandals and they're all footwear, but they're designed for a different environment and a different concept. So, uh sadly, in the past, there's been this an idea that they're competitive. There's a, it's either or, but no, it's both and, and one complements the other. And we're going to talk about that. The team from Lanarkshire are going to talk about it and doctor Alistair Ewing is going to talk about it in a moment regarding the national Digital platform. So I think Steven I'll leave it at that. Great. That's been amazing. Robin, thank you very much and Robbins going to stick around for the panel discussion at the end. Um If you have a question for the panel discussion that you want to put everybody, if you just highlight that right panel discussion in your question, um Stick it in the chat box and the messages and I will come to that. So I'm running over a little bit, but I thought that was really important to hear some of those questions answered by Robin that you put in the chat. Our next speaker is ours, Karen Morrow and Dr Jack Fairweather. Um, so Karen is a program manager for realistic medicine and the NHS Lanarkshire and Jack is a consultant Renal in general physician in uh the University Hospital mcglynn's. They have both been fundamental in the introduction of steps in Lanarkshire building. And work started as far back as 2016 where I think they have a hospital um uh TEP uh equivalent. Um And so they have a length and breadth of experience that they're going to share with us. Um They're going to give us their lived experience of implementing treatment, escalation plans, their journey, the barriers they encountered and the solutions they found. So, um I shall hand you over to Karen and Jack. Thank you very much Steven. Um So I'll just start off and thank you for the introduction. Um And as you said, Jack and I have been involved in this, but I'm certainly not on our own and we will acknowledge that at the, at the end of our presentation. Um So Jack and I will do a double act for this session. Right. Correct. Thanks Karen. So, yeah, we're gonna spend the next 20 minutes talking about, about our experience in N H S Lanarkshire when it comes to really to a specific answer to one of those last questions just post they're in the chat. So we're gonna talk a bit about the background to treatment, escalation, planning and N H S Lanarkshire, all the Robin helpless. Already alluded to some of that. We'll update you on where we are now in our current challenges and talk about really exciting recent work where we've brought tep and respect together. We'll illustrate that finally with the case discussion and then touch on next steps for us in N H S Lanarkshire before we take time for some questions. So um treatment escalation plans in N H S Lanarkshire been around for well, well before my time in in N H S Lanarkshire and it goes as far back as 2016 when Professor Taylor really lead the work with what at the time were introduced as hospital anticipatory care plans and he's been in the cars there for about seven years in Lanarkshire, but through various different iterations and can happily spend much time talking about that. And more recently, we've been using what was then treatment and escalation and limitation plans. And these have now evolved to just been test treatment escalation plans. And these are used now in three acute NHS sites across all specialties for all of us, all in patient's across the piece. And, and, and they've been up there, been ups and downs but much of this was followed, really intensive implementation that Robins already described where he really went around the house is speaking to almost every clinician in N H S, Lanarkshire about the process, an individual 1 to 1 training kind of program really just highlighting the scale of of intervention required for implementation and roll out for treatment escalation plans that's been undertaken any Chest Lanarkshire. And as we already seen, we've got really strong evidence demonstrating benefits including evidence undertaken locally, looking at hospitals where I'm presenting from now showing a significant reduction in harm's and avoidance of non beneficial interventions for patient's with treatment escalation plans in place. As I said, the treatment escalation plan and the document and the process have evolved um in in many different ways. Um as many people discovered in and certainly other boards across Scotland encountered treatment escalation plans really came into the road. I think a lot of the time during the COVID pandemic and much of our approach changed during the course of COVID. And certainly we evolved it so that every patient coming into the front door was receiving a treatment escalation plans. And we've been using feedback at each stage two to evolve the plan than the way it's been used, including at times plans for every different specialty, including lots of different specific medical interventions and then more recent changing changes, reflecting feedback and and experience that we've had. And so following on from that obviously with the introduction of the COVID and non COVID plan, as Jack has said, um we have captured feedback throughout our process is an important aspect of the feedback was if someone was admitted with abdominal pain, but tested positive for COVID. Which plan did they use the non COVID or the COVID one. Um So that led us into working together to, to develop a revised plan and it was the the revised treatment escalation plan. So it removed that element of limitations. Um And, and that was to be one size to, to fit all. Um We developed an s far an expert to communicate with our workforce, but fundamentally, we then lead that onto a standard operating procedure, but like everything, um there are limits to what people will read at the time. So following in the footsteps of Robin, many years ago, I went round all of the three acute hospitals to engage with every ward um to capture the medical staff, nursing staff and uh a allied health professionals because we recognized in the revamp of of this revised plan, it was to be a multidisciplinary approach. Um And certainly, yes, there would be the final agreement with it, the consultant and the team involved in the patient's care. However, it was important that there was the recognition for whom is looking after the patient. If there were concerns, then a treatment escalation was the right discussion to have staff awareness was was fundamental to this, um an initial audit, just a snapshot that was carried out several months after the revised plan indicated about a 30% uptake of the revised plan. So what could it do to make that better? So, we initiated a further combs message and through our staff brief and through the pulse providing an article um and then a follow up of a formal audit and as already alluded to in the formal audit lined with our mortality, our annual case smoke mortality review. And it was encouraging to see that 66% of the patient's reviewed did have some form of treatment escalation. And actually, um 63% of them were the revised plan, which was a 30% increase from the previous um snapshot audit. Similarly um of that there were a few patient's within the case note mortality review um of which was about 16% that did not have a treatment escalation. Um And again, um as as Robin has mentioned where there is a plan and obviously reduces much uncertainty and the difficulty and that was, was trying to decipher much of what was written and repeated within the case notes. Uh Slight. It's just uh take a moment. Mhm Sorry. Bear with us. But Stephen, are you able to see our slides? They've gone blank with us. Uh No, not at the minute. Um uh um Let me if you try it slide, six or screen screen has gone blank. Can you scroll past it? No, it's all blank. Sadly blank. Um And even going back the way that we were blank now here, I wonder if we, if we stop presenting and then just try again, just try uploading your slides one more time and then if you can't, then I will upload your slides. Yeah, we're still getting nothing. Sorry. No, it's saying our slide deck is, is, is they are ready for presenting but okay. Just give me one moment that has gone. Yeah, sorry folks. Sorry about this. That's a nice. Yeah. Um I will try uploading your slide deck and go with that. Thanks Stephen. And then we can uh we can have a Christmas the moment next slide, please. Yes. Uh So maybe we're slide tooth like three, same another. So you were at slight number six. Uh Yeah, that's right. So this slide here. That's perfect. Yeah. Thank you technical error. But um when you shall get there, thanks Steven. So we're just gonna take a moment just to look at the current iteration of our treatment escalation plan and just highlight some of the key aspects that we've found, as I say evolved over about seven years or so. And so the first thing is the, the yellow box criteria at the beginning. So this is why we identify who should, who should be recommended, who should be considered for treatment escalation plan. And, and this is our approach in N H Islamic. Sure we've moved away from are kind of everyone at the front door, everyone who's being admitted, we're not taking approach that, that there should be in selected patient's and we give some guidance here, but it's, it's pretty obvious. Uh We're talking about beautiful who we recognized as being at risk of deterioration. After admission, we, we've encompasses the clinical frailty score based on evidence about your survival after cardiac arrest. For instance, we've also highlighted issues about people with life limiting disease. It's really all of the fairly obvious things, but as I say, encompasses that group of patient. So I think we all know who we're talking about. But but specifically, we're not talking about using treatment escalation plans for every single patient admitted. The next session of the form looks about engagement with the decision making process and capacity for making decisions and that obviously fits with the legal necessities about these kind of decisions. And then the key decisions that we include on the treatment escalation plan are noted there in the colored boxes that we're talking about the full escalation for want of a better term uh including resuscitation and potential referral to intensive care. We talk about selective interventions in high dependency units or kind of level to care environments or selected interventions, but award ceiling of treatments. And then we we include patient's who are really for palliative care only where symptom control measures only. And then we make a very clear um annotation on the treatment escalation form about whether or not attempt resuscitation should be made in the event of cardiac arrest. But this doesn't replace the national uh DNA CPR form, which is obviously still in use. We include space for the document to be signed by the person completing the form, but also to be countersigned by the senior clinician responsible for the patient. On the reverse of the page, we include a section here for common medical interventions and and we often find that this is actually not filled in in the number of cases, but where it's filled in, it can be really very useful. So, annotating whether or not patient should, for instance have arterial blood gas sampling. Uh and then a space for free text comments about which interventions would be appropriate or which would be inappropriate. And this is frequently where I would write things like your renal replacement therapy inappropriate or ct scans inappropriate. For instance, we include a section about who the patient who this discussion has been had with. Um And the you have a bit about that but it shouldn't replace conversation still being recorded narratively in the clinical notes and a couple of decision making and communication aids that are included here including the scoring system for the clinical frail to score and the red map guide that Robins already talked us through. Uh And this is the iteration of the treatment escalation plan that we have in use currently and it continues to receive very good feedback from our clinical colleagues next slide please. Um So following on from before when I was mentioning about engagement. So in order to um from the formal law that carried out at the towards the end of last year, how could I keep the momentum going? And so using the model fel improvement in methodology around PDS A, I started work with uh two wards, a university hospital, Mom Clings. And although that seems small, but I find that starting small and being able to tease out all the different little glitches and challenges can then make it much easier for the next two wards in the next two wards, etcetera. Um So thinking about that, um much of it started with observation. So what actually is the activity when it is their opportunities for treatment, escalation, discussion's within the war processes. So looking at handovers board drowns ward rounds. Um I'm looking at multidisciplinary um discussion's that that happen um identified there's various ward processes. So going from one more to the next, didn't always replicate in the exact same way. However, I recognized opportunities where a prompt could be taken. Um And that's something that started quite recently um as part of a work through operation flow and certainly driven through the unscheduled care and demands currently. But the whiteboard, um the whiteboard um is led with the ward doctor and there is much discussion and on this, there is tape included. Um And whilst it's part of the conversation, the next stage two actually has the tape been completed. Um seems to be the more difficult element of it. And around that, it's that element of um disparity around whose role it is a to actually commence the form. And as I said, we developed a standard operating procedure. I mean, reiterating that with the multidisciplinary teams that whoever has a concern about a patient's condition um has the support of the organization to initiate treatment escalation. Um Again, I mentioned before around version. So I found a several different versions. So again, linking with the ward, a clerical staff to ensure that there's the right tool, thinking about visual tools to help um staff to understand. So we did a quick guide um that demonstrates that the process for initiating a treatment escalation. But again, thinking about how we can make it more visual. Um So having some um laminated documents, etcetera next to the, to the whiteboard, um We're now on a cycle four of the PDS A um which is now leading on to the next stage of the conversation if we can initiate the treatment escalation. What happens after that next slide, please? Thanks. So as Karen said, we've, we've made a lot of progress, but we still have recognized that art abuses still probably sub optimal. And we've also increasingly recognized that there's an element of quality that needs to be considered here that, well, we might have document complete completion as a raw statistic. There's still the risk that some of the processes are still suboptimal and like quality and a recognition they're that they're probably attempt done badly is, is almost certainly worse than not at all. So we spent some time focusing on quality and, and also about streamlining use and thinking about avoiding repetition and, and focusing on making sure that information is available to clinicians at the right place. At the right time, we find that that we have a frequent, a high number of patients who are often using unscheduled care repeatedly and might have been through a tep decision making process over and over again and often as unnecessary and sometimes even harmful repetition and this particular risks and and challenges around the interface often between hospital admission and discharge and communication and with primary care. So we're recognizing there that there are some holes and, and where we are just now, which is what's driven our next movement, next slide, please. So this is where we've started to introduce the respect process in alongside tepes. So I'll just briefly touch on the respect document. I suspect many people in the audience will know this but respect is a UK wide um initiative and and model and the recommended summary plan for emergency care and treatments and it's very well established process. But it involves a discussion between patient's often their families and the clinicians. Um and it allows a documentation of wishes and recommendations for care in an emergency situation. So the top of the form includes some demographics. And then a key part here is a shared understanding of health and current situation. And what's really important there for me is that, that, that mandates a prognostic conversation between the clinician where you're handing over that information about where they are and then focus on what matters to the patient where their preferences lie, what, what they value most and what they really want to avoid. And then the final part really allows a very, very specific and finessed focusing on, on specific treatment recommendations for use in emergency, including a note there on whether or not resuscitation is to be planned in an emergency situation. So this is the respectful and as I say, we're now bringing this in alongside treatment escalation plans. And with the next slide, Karen's gonna talk us through how next slide please. Thanks. Um So this slide is it is a demonstration that I had pulled together because recognizing engagement and having the 1 to 1 conversations, I developed this in order to make it a visual tool um to be able to communicate what was in my head and how treatment escalation and how respect as an anticipatory care planning um could work together. The example here in the infographic demonstrates where a digital respect has been completed within the community setting. Be that in a care home or with the GPU in, in someone's own home. However, there has been a call, they attend the hospital through our patient management systems. And for track care and clinical portal, there is an alert when the chi is entered into the system that alerts that the first assessing healthcare professional and to recognize that there have been documented in goals of care and, and a personal wishes um for the patient um that can then demonstrate if there's the appropriateness for admission and or to facilitate that discharge transition back into the community setting. If for admission, there is the recognition that there were goals of care demonstrated in the process and that then determines the treatment escalation plan. During the the the hospital admission, there is a recurring share decision conversations and review for the treatment escalation and then ultimately leading towards the discharge, there is a consideration for what treatment escalation plan a goals were put in place and how they link with the original respect process and what changes we are required to be made. Um In Lanarkshire currently, we are still in paper. We're hopefully soon to go live with the digital respect. However, once we are digitally live the respect process that is updated and refreshed as part of the interim discharge planning um will automatically send a copy through Darkman to the G P practice the GP looking after um and will be accessible through the document process on two EKGs and through vision that's used in primary care and similarly working alongside um with our other partners such as Scottish ambulance service and our community district nursing teams, etcetera um for the systems that are used and the information that was agreed as part of that discharge plan will be accessible for all professionals. But similarly, again, depending on the goals of care that were determined, there may be a subsequent admission that is appropriate, but the levels of treatment will evolve through time as agreed with the professional and the other professional, the patient next light. So just to highlight them that the respect form sits with the patient's wherever the patient would be in the community. Um And, and the respect form can be generated in a variety of different uh kind of settings. As Karen's illustrated, that might be at the time of hospital discharge from the patient's going back out into the community community, or it might be when the patient attends a hospital clinic or is seen by a specialist nurse or in in a different environment. Or for instance, if they're discharged from the hospice or attending a hospice for symptom control reasons, or indeed, in many cases, could be generated in primary care. And ultimately, that reset respect process sits with the patient and the decisions are documented there clearly such that at the time of crisis and an emergency, it can then use to guide decision making and that might result in a further hospital admission, if that's appropriate and in line with what patient's wishes and, and like the outcomes are going to be, or it might often avoid hospital admission, which is a key area for improvement work uh and might return a patient into an alternative environment, for instance, a hospice of actually, this is a patient approaching the end of life. But ultimately, wherever the patient goes or either if they stay at home, the respect form allows the goals of care to be clear, obviously revisited at the time of crisis, but allows allows those decisions, make decisions made to be clear. Next slide, please. So thinking a bit about that respect form and why we think it's useful in this circumstance. As I said, it really is just about identifying goals of care. It works very well and it in various different settings because it largely relies on free text that allows for a lot of flexibility. I know my colleagues in palliative care might spend an hour with a patient talking through a respect process at the time of discharge from hospice or in my practice, it might just be a five minute addendum to a clinic conversation where we've discussed prognosis, prognosis, goals of care and maybe made some decisions. And often times this is a dynamic thing that might evolve with numerous conversations. And it and for us, it really usefully documents those conversations and that plan and particularly with the digital solution allows that to be held in real time in all of the different settings that needs to be. So it's available to secondary care or to GPS or out of hours. And indeed even hopefully the ambulance service too, next slide, please. So what about tip and respect, how do they work alongside? So Robin's already spoken to this to some extent and, but I'll talk now about our experience. I, I firmly believe that these are not two of the same thing and I think they probably do fit well, the idea that there are two different kinds of footwear, but one for one and one for another and there is an awful lot of overlap. And I can certainly understand the arguments where respect probably does the job of tip. Why would you have, why would you have both my own view is that they do meet slightly different purposes, particularly in emergency circumstances. It's absolutely essential that there's real clarity about where the escalation decisions lie. So that if you're the medical junior doctor at three in the morning and somebody's, you know, the emergency buzzers going and you need to make a decision quickly, you maybe don't have time to run through all of the detailed free text that might be included in a, in a respect form. But you can quickly see all this patient is someone who's been deemed for full escalation. It's time to call my intensive care colleagues. You and the quick ease of use that the treatment escalation plan allows. And it also goes into many very specific hospital interventions um that that, that are really required in hospital but often very meaningless to primary care colleagues. Whereas respect is much more appropriate for that setting where you can make a bespoke plan relative to the individual depending on their stage of illness. And it might be something that's relevant for the coming days or weeks or possibly even for the months and years beyond and particularly given the functionality we're gonna hear about shortly. The respect uh digital platform is going to enable this um tool to use in a very practical way. Next slide, please. So where are we now? So in Lanarkshire colleagues, Doctor Cook, um Susan Cook, one of our palliative care colleagues has really paved the way with respect in N H S Lanarkshire and it's now standard practice for patients who are being discharged from hospice is to have respect forms completed at the time of their discharge. Clearly discussing their goals of care and future plans. Primary care colleagues have really driven um improvement work looking at care home residents, you know, in many centers will all have respect plans. Um And we recently are developing a test of change and an acute setting using a renal service where we have lots of frail, multi morbid patient's and and often very invasive, sometimes very burdensome interventions and a large number of unscheduled care admission's with lots of in patient's is a really useful opportunity for us to develop the combination of using TEP and respect in these patient's. And so this is where we are now in N H S Lanarkshire. Um And, and hoping to see that develop as time goes on next slide, please. I'm just very briefly going to run through a case discussion just to illustrate some of the points that we've made here, Many of them, hopefully fairly straightforward. So this is a familiar case for many of us in the receiving units. So I'm a multi morbid 81 year old patient where the background of hypertension diabetes, airways disease who had COVID in November hasn't really got out the bit increasingly dependent. Now, housebound, losing significant amount of weight. And prior to her presentation had a clinical frailty score of six and at the front door, she's unwell with a new score of seven, uh a diagnosis of uh of sepsis. Next slide, please. So this is a point where the team have an appropriate prognostic conversation with the patient and family and identify that she's frail and poorly in the background and that she's currently really physiologically challenged. Uh There's a discussion about goals of care and what we're aiming for here and some share decision makings establishing that we're not gonna invasively investigate a weight loss and while she's being treated aggressively, but at award ceiling of treatment, there's going to be a D any CPR and we're not going to be taking things further than that with antibiotics, fluids and oxygen. Next slide, please. So all of that was documented on the in hospital treatment escalation plan and as time has gone on, the patient has as many do survived acute sepsis issues has gone through a process of rehabilitation but has been left with significant functional impairment and it's now getting to the stage of hospital discharge And this is an opportunity for a further conversation. So this is where I would have a reflective conversation with the, with the patient and ideally her family, talking about the treatment she's been through and what she found. And in this case, she found that, you know, while she was glad to have survived, she found the repeated any puncture necessary to keep her on IV antibiotics was really torture for her. And while she was up for it at the time, now that she's been left with significant functional impairment, she doesn't really fancy going through any of that again. And so we're able to make some decisions regarding her future care. We will keep the D N A C P R and that will remain in place and we'll communicate that into primary care. She's making a clear decision at this stage not to be re admitted in an emergency and has made some decisions about her preferred place of death and how, how she would like to be cared for as she comes to the end of her life. And all of this at this stage is now documented in the respect form which will be available in primary care, available on clinical portal for other secondary care clinicians. But also crucially, we recognize that this is a dynamic and flexible thing that allows for adaptation. As time goes on, we might find that she gets home and thrives in which case, some of the decisions that she may she has made may need to be revisited and with the digital platform that will be uh readily possible. So here a clear illustration then in fact, we've used the treatment escalation plan at the point of presentation, acute physiological threat, where we need to have some very clear specifics about how we look after in hospital. She's come through that admission but remains unwell and frail with very high risk of further deterioration and and the necessity for us to document future goals of care and future care plans and the respect form for us works very well for this. Um And so making the making it easier to do the right thing I think is Robin put next like please. So thinking about what our next steps for treatment, escalation and respect. So obviously, for Lanarkshire and fundamentally to go live with our digital respect and, and joy and join forth Valley and Teesside in Western Isles and Borders who have have gone live a digitally um the relevance of that obviously is fundamentally the connection and the connection for all healthcare professionals um to do the right thing for that person, irrespective of, of where they are being in a hospital setting or at home or in a care home. Um Wyden R N N map engagement. And the reason for that is we can have recognized that our end maps tend to be a more static workforce, recognizing that trainees obviously retake, they don't always receipt within our our own board and they will move around. And so therefore, if we can heighten um the discussion prompts around our end maps who ultimately will be the prompts with their, their medical colleagues to ensure that the right documentation is with the right patient for the right treatment at the right time. Um And thinking of that where we have um we have an alert uh that will recognize if there's a D any CPR, if there's a respect in place, we would also why not think digital tip where that would also link. Um And all the relevant documentation is together. Um The next slide, please, Steven is just to quickly acknowledge that obviously, Jack and I are here presenting today, but we wouldn't have been able to do this without obviously working very closely with her colleagues, Doctor Susan Cook, Doctor Calvin Lightbody, obviously, um what Professor Robin Taylor had initiated initially in, in Lanarkshire and with the support of our realistic here healthcare group for Lanarkshire that has given us full support in order to take this forward. Um And the last slide was just to, to, to ensure that we had encompassed what we'd set out to do the presentation so we can end the slides there. Stephen, thank you. Excellent. Thank you guys very much for your presentation. Um Um Very good as, as always, um I have a few questions, I'll take a few questions from the chat as well. So if you want to add in some more questions there, um so we can interact with the speakers. Um That'll be amazing. Um I guess going back to the implementation of things, implementation of Tepes. Um What was the, do you have like a top three? I'd say a top 10, but time is limited, a top three things that pushed implementation forward. What are the sort of three things that jumped out to you? I suppose um a key point in feedback has been around from work force feedback from workforce about fear of doing the wrong thing and not knowing what the right thing is to do and, and it's been spoken of the three AM situation in the morning um and the difficulty having gone through the case note, mortality of you. Um It's disheartening when you're reading a repetitive entries into case notes where at the same time you're reading around a deterioration that's happening or futile treatment that that is being invested in. For me thinking about it from the realistic medicine point of view and thinking about the shared decision making, about reducing harm. Um Now thinking about our value based approach, um the feedback actually from our workforce is important and it's relevant and, and, and if we can't act on that in order to support them with the implementation of uh a process that is reasonably simple. Um And actually again, in the case note, review, when there is a treatment escalation in place, you know exactly what the plan is for that, that patient. So um for me that is that is the key point. Um and part particularly of considering over the last few years, um staff health and well being um is a very important factor in order to retain our workforce. And therefore, if we can reduce the anxiety's associated with that, then doing the right thing is having tip. There is a question from Connor in the chat that says that if you filled in properly completed respect form. Um Could you just scrap tips? Um because does that not just provide the guidance to the team about the sort of acutely deteriorating patient? Um And would that not just help with less paperwork and duplication or do you think that the tip adds something additional? Yeah. So I think that's a really good question and I don't, I don't profess to have the expert answer in this. And I think we have to be realistic about where our background is in N H S Lanarkshire and that we have your many, many years of experience, you're born through really hard labor and intense intervention, getting tep rolled outs. And I think even just looking at the challenges have been associated with different versions of TEP and, and iterations changing the way tepes been practiced. I think there'll be a real risk that any major change. You know, for instance, if we got rid of Tep and replace it with respect, I think that would, that would be a real risk. That said even if I was given a blank slate and kept didn't exist in Lanarkshire, I would still opt to the model we have with Tepfer in patient's and respect for outpatients. And I think for me, the most crucial aspect of that is it necessitates the second conversation. You might have that goals of care prognostic conversation at the beginning when the patient's first admitted and you might establish goals of care in the treatment escalation plan then, but that needs to be translated into something meaningful for the patient, their family and for clinicians in the community at the time of discharge. And so actually having the to having tipped for that inpatient stay and then respect means that that there's a, you know, there's a necessary distinction. I think there's a real risk that you might have a respect form or whatever, whatever it is filled in at the front door that doesn't get considered again at the very end and then you still are left in no man's land without people knowing what the goals okay are at the time of discharge and, and respect, I think fills that hole and it also affords the flexibility. And I think looking at the comments of people who you and speaking to colleagues who do work in environments by respect is used in that acute setting. I think the key component of that question is if the respect form is filled in correctly. So that, that if is quite a big if and if you're the med reg at three in the morning and someone's got a news of 15 and you and the intensive just need to make a decision quickly about whether or not they're gonna get tubed. You really need to, you need to, you need not to spend 15 minutes going through the detail of the uh free text narrative in the respect from you really need to see that tick box. What, what are you aiming for in, in this admission? And that's where I think the tape affords that emergency decision making. The respect sometimes doesn't allow it unless it's done properly. But the sad thing is we know that it isn't done properly all of the time. Maybe a quick question. There's um the interface between tepes and D N A C P R and I supposed respect and D N A C P R, the question um it wasn't Connor, it was um it was further up, sorry. Was Alice who said if you come in with respect form that says D N A um CPR but no official read form. Should the patient be resuscitated? Um How did the two go together, I suppose is the question? Yes, I think at the moment I think this is a paperwork thing essentially. I think if you've documented a decision and a document and a discussion and it's clear that A D N A C P R is in existence, then then in my own practice would be just to translate that into a rewritten red form. A D N A C P R form at the front door. Even if you, if the form is not there, I'm hopeful that in time, the digital solutions here are gonna going to make the difference. And I think respect digital platform is really going to allow for that particularly because it's going to be flexible and dynamic. It's gonna allow for new versions, new iterations of those cons negotiations, you know. So there's not a question of whether or not the D N A C P R has been revoked at the point of previous discharge where we are currently, we have a separate D N A C P R decision in line with N H S Scotland policy. But but we very firmly fixed with the idea that no DNA CPR without a TEP. So in, in patient should all have a D N A C P R with a TEP form and, and where d any CPR has been agreed either in the community or in hospital, they should still have the D any CPR form. I think for Scotland, we need to recognize currently that the red DNA CPR remains a legal document. So as Jack has, has mentioned, um if it is documented within the respect, but there's no visible red form, then one should be initiated because it is a legal process currently. Yeah, I think we have the same thing and uh that uh if you are doing a D N A C P R for then a TEP gives you the information up to that Ian has put in the chat. The D N A C P R is like the full stop. But the um at the end of a full paragraph of the TEP form it um if, if that's the appropriate um direction for, for that patient, I'm kind of looking through the questions as I come along, they're coming in thinking, I noticed there was a question Stephen around patient or family perspective. We have captured through the testing of, of respect from patients' and, and families and from staff and the feedback has been positive to the extent where patient's have commented that they feel the involvement in the respect process can reduce burden on their family to be making decisions about them. And perhaps not always with them. Um And likewise for families to say, um this is the first time we've had this open discussion, it was difficult, however, very helpful. Now, I know what my parents, relatives wishes are. Similarly for staff who have experience of working with um the my A C P that continues but was in existence before that was quite a hefty bulky document. And they feel that the respect process is captures in essence what is required in the event of the next emergency admission um or the next emergency situation. Um And it's been helpful and the flow of it is quite streamlined and actually has AIDS and Susan Cooker own um consultant who kind of started to lead on the respect process had said and she's open label share that she thought she was quite good and actually she's changed her practice um since using respect. Uh So, feedback has been positive, particularly from patients' and their families so much so that certainly much of the evaluation has been a yes or no or a tick box. But the free text that we've received back in return has been um quite helpful. I have I have another question for you. I'm mainly gonna leave it for the panel discussion the end, but I'll post it to you just so that you can think about it. Um And it's about that interface between tepes and um A CPS um or respect going into primary care and the thoughts of the primary care team around that because I think those interfaces are very important and it's something that you guys are a way ahead of us on up in Grampian, especially Calvin like body. One of your colleagues um saying from a acute admission perspective respects a little bit too vague. Um uh The tep odds clarity, which I think is Robin chatting with the different para shoes. Um um The Christians put something about when respect and captured digital, digitalized and this is a good segue into the next speaker. Um We will see about that and um uh Connor is at the start of putting things into, into place. Um And Donna's um their tips have a space for discussion's can be documented with the family. And I think that is the crux of it having that aims a treatment discussion with the patient, their families and their carers. I'd like to thank you to very much for your ex and presentation. You're gonna stick around to the panel discussion, the answer, there's opportunity for more questions. Then Robbins appeared on the screen to tell me I'm running behind. Robyn is going to introduce our next speaker who's all through you. Uh Thank you. Well, I want to express it. Welcome to Alastair Alastair Ewing Alistair work. You never know Alistair whether to say your NHS education or NHS inform. But, but maybe you can correct me in a moment. I think there's not a lot to do by way of introducing you because the platform already has been created by, by the discussion, both the chats and the discussion, the presentation from Karen and from Jack. But Alastair is working on the national digital platform. Respect is the is the number one prototype for that platform. But I think it's fair to say that we all realize that whether it's tape or respect heading in the direction of the digital, the digital to world, so that there's cross talk between primary care and secondary care. And even within, within primary care or within secondary care is going to be a key element in getting this to function in a satisfactory manner. So I'm going to hand over to Alison. He's going to give us a little bit of an insight into the technicalities of this where it's heading where it's reached. And so Alice over to you. Uh Thanks Robin Robin. Can I just check, can you, can you see my slides? Just uh that's great. Thank you. So I work for NHS Education for Scotland. I'm a product manager. And you might ask why, why is someone from the board that does education for NHS Scotland? Why, why, why am I talking? Well, uh the reason why talking is within, within, there's within HHS Education Scotland. We have a, a technology directorate and we've been building technology for a while. The building education and workforce systems for quite a number of years and more recently. We've been commissioned by the Scottish government to build out the National Digital platform. So that's why, that's why I'm talking, I'm not a not clinical person. I'm a, I'm a digital person. I'm a product manager. Uh We are set up like a little software company to build software within the N H S. And so I was going to talk about today was a little bit about the platform, a little bit of one of the products we built, uh you know, an example of a care plan and then talk a little bit about where we are going with that. So to, to kind of start that set the scene, the reason why our organization was set up and why, you know what we've been commissioned to do is is all down to the Scottish government's Digital Health and Care strategy. Uh And in that, it is very clear statement that, you know, we will build a national digital platform and the point of that platform is to provide clinical data at the point of care to, however, it's providing that care wherever they are providing as well. So this is not, this is not hospital dating uh digital health and care strategy. This is about, you know, whoever is providing that care wherever they are, it's about providing a common architecture for innovation and what that actually provides means we end up building cloud systems and I don't want to lose you all with a cloud conversation. But for me, Cloud is all about people, it's all about having the information for the, you know, the people of Scotland in a single place that can be accessed. It means that whoever's accessing the data doesn't need to be in one place that the data is not being stored in a single server somewhere. It's being shared across the country. But it's also potentially about being able to share that data with, with people themselves. So they can have access to their own clinical data directly from within a national digital platform. And then the third part is really to allow that information to be used for research and quality improvement perspectives. So, um while I'm gonna mostly going to talk about care plans are our biggest product or the, the product that we're most well known for in Scotland is our vaccinations products. We, we mentioned earlier on how there are some of the tet work have developed pace through COVID and from a digital perspective, there's lots of work that also progressed a pace through COVID. And, and one, you know, our best example of that is the vaccination system. And so before COVID, uh we didn't have a National Vaccination service, you know, but then that came along very quickly, uh we have managed to stand up digital system which would allow the vaccinators to be able to find everybody in Scotland and identify them and be able to record which vaccinations they had and then behind the scenes, we built the system that kind of manages that National Vaccinations Database and, you know, started off with COVID vaccinations, but now has been extended to flu vaccinations and pneumococcal vaccinations and a number of other vaccinations. So it's kind of grown in time from that, those original kind of COVID roots. And I think that the vaccinations um so that we couldn't have done the vaccinations work without cloud technologies, without modern computing technologies, it just wouldn't be feasible. We couldn't have done it's fast enough, we couldn't have rolled, rolled out across the whole of N H S Scotland in a matter of days that didn't happen otherwise, you know, in previous times, rolling out products or even examples of testing able to that standardized across Scotland really, really tricky. It takes a long time where it's a vaccination service because we're in the middle of a pandemic really happened overnight across the country. And that was amazing, you know, getting around to work together. But also had a really interesting, the vaccinations really interesting from being able to share this datas a while this data was captured in a health setting. Uh it was shared, shared widely. So, you know, we, we potentially we could have our vaccination records on our mobile phones so that it wouldn't allow us to go traveling. So the share ing of data was a really interesting aspect of, of what vaccinations helped us understand. So that's what I was going to do, what was going to do is talk a little bit next to be part of the conversation we're having today is to talk about one of the other products that we're, that's being built on top of the national product platform, excuse me. And that's uh respect. So that's matching up with what Karen had been talking about in Lanarkshire. So I've included a copy of respect form system, just a test system. And this is this is what the outputs of our, our product looked like a respect product. It looks like a respect plan. The top half of the printed form is about the person's own understanding of their condition and what matters to them and you know what they fear and what they wish for. And then the bottom half capture those clinical recommendations that was talked about earlier as well as the, the CPR decision or recommendation at the bottom that's highlighted in red. And so because it's a, you know, because it's a digital planets formatted and we don't have to worry too much about doctors' handwriting. It's all nicely printed is already we have a bit more accessible. But the the things that we liked about respect respect as Karen mentioned was chosen as the first, the first thing to build on top of the National Digital platform we wanted to use, we want to use products to understand what, you know, what are the components of a platform that we need and we use products to exercise that or to kind of guide us. And so we liked respect because it was, it's quite simple, you know, it's, it's only, it's a two page form. So from a digital perspective, there wasn't, there's not lots of complicated, not lots of content or complication. It was, it was very well defined uh been well designed by the Resuscitation Council. So someone had taken the ownership of all the hard work of making sure it works and it's captured the right information and that's laid out correctly, sort of branding and the color and all that layout that was really helpful for us. It means we didn't have to figure that out. So it's nice to page, nice and simple. It was, it's been adopted, it's widely adopted. So within, with many trusts in England, it's being used. So it felt like it was, you know, had good, you know, good um good foundations and a good candidate to, to use in Scotland. We liked it because very patient centric, you know, the first half is about what the patient understands. We liked the aspects of supporting realistic medicine and supporting those conversations. We liked the fact that the purple form was there and it was distinctive and it could be captured the information and we really liked the way that it, it wasn't just about, you know, our organization has been set up to share data between health and care. We like that respect wasn't just about, you know, what happens in hospitals. It really was a much broader uh conversation in hospitals and secondary care and primary care and community settings and that people were involved themselves. So it's a number of aspects that made uh respect, uh you know, a good candidate for that first, that first prototype for that 1st, 1st product to build. And so um my next slide, I'm going to go and talk about what we, what we built and what the, you know, what the key aspects to uh to what we built for a digital care plan. And this could apply to any care plan and we chose to apply it to respect in the, in the, in the first instance. So from our, from our perspective, we were thinking about digital solutions, we want it to be a, a national system. We want to have, you know, a single, you know, a single product that could be used across the country. And, you know, today there's been, you know, lots of the health boards doing different things and that's really slowing innovation. Uh having a single thing that works, uh you know, allows, allows, you know, a digital approach or a national approach to, to take place. We have a single system that everybody in Scotland fits into a single system. Um You can, that information can be accessed from anywhere we put controls around it to make sure that access is safe and secure but it is, it is a national system. So we don't have, we don't have one copy for tasing another copy for uh for Lanarkshire, it's just a single system. So as, as people move, you know, as we move homes or they move locations for care, uh the data doesn't move, the data stays in this cloud system is accessed by whoever needs to access it. So we, we want to make it accessible. So we, we, we built it for a web page. There's no installation, you just connect to a web page and that will give you access to it. We make sure that you're allowed to do it. So the permission side of things are done through NHS Scotland's office, 365 logins. Everybody has one of those who works for uh NHS Scotland and uh partners and in primary care and in the community. So if you have that identity, that's what, that's what lets you in. So that made things simple. You don't have to remember another password means the health boards are in control of who can have access to it or not. And one of the things that was mentioned earlier on in the talk was just important for the this this information is about person. So we need to make sure we've got up to date information about that person. So having the demographics linked is another part. So we, we made use of the national digital platforms, Demographic service. So that allowed us to make sure that we had that more subsidies, eight patient information. And we presented that as part of the a part of the user interface to make sure that the clinic, the clinical teams who are filling in, know who's being able uh filled in for make sure that patient safety is considered. Um And then the final three things that we've, we've, we've learned from building. So I've been really pleased to join this conversation and hear about how much learning has going, been going on, about trying things and working it. And so one of the things that we've learned when, when we, we put this live about three years ago in Forth Valley and quite quickly, uh we realized that we were missing a future. So what we realized was when the clinical teams were using it, it was, was it wasn't very frequent that the, the clinical teams could fill in the whole form in a single shot that the clinicians were being uh you know, disrupted or taken away or, you know, it needed. And I actually needed a bit of a conversation with a number of different people. And so what that led us to build was uh to support more about teams collaborating and being able to collaborate through the, through a draft feature. So the idea in a in a hospital setting might be that the, whereas the, you know, there may be a senior clinician has the conversation. Maybe a junior, junior partners would write up the conversation and need the, you know, the senior clinician sign off or maybe outside a hospital setting. It might be that the, the conversation and the initial right up of the plan was written by um you know, maybe by some of the care home team, a care home team and then their clinical partner of their GP who works with the care home was the one that could provide a clinical sign up. So we kind of discovered through working with clinical teams. In fact, helping collaboration was a kind of a key feature. So that's what we've added that. And I think that helps that, you know, previous um things like the emergency care. So, I mean, it's only GPS that limited wears respect is a much broader um church with more people being able to contribute that. And so the digital system allows that to kind of support that collaboration. And as was also mentioned, it also supports when, when things change, you know, person, clinician condition changes and they want to change your mind about how they haven't said it's much, much easier to update a digital system that we don't have to, you know, start from a blank page again. We don't have to be scoring things out. We can, we've got the information and we can take that forward. So the last two points were really about I think what's the real key bits of a digital system? It's all about share ing so our first bit was quite a straightforward reassuring. So while we're building a digital system, being able to give the person themselves and their family a printed copy of their respect plan is there is a really important part that they, the person still feels it. They've got something tangible, they can put it in the fridge of the handbag or you know, wherever they want to take it. So being able to give that formatted respect plan is an important part. So we made sure that was there from day one, but also being able to share the information and respect across the system, being able to share it so that anyone in the case of emergency has access to that. And so that's what we've really been working on most and I was going to show you what that, what that looks like for most people. So um I was going to start by showing you. So most um in the acute setting, most health boards in Scotland have a clinical portal and a number of different clinical portals are in use. And so this is an example is again as a test system, it's not a real patient information. And Karen, I think this is one of your um clinical portals. This is what how it looks a little bit in um in Lanarkshire. And so if a person in Lanarkshire has respect for. There'll be a little alert that pops up to kind of highlight that this person has a respect plan and then there'll be a link to the respect plan itself. You can see there's a little hover over that view document so that all of the clinical teams who are in the acute sector can have access to that, see that that relevant information, this respect information is available and then go and see the formatted purple document itself so we can get access to that. So imagine if you know person's arrived in A and E and the first thing to do is any checked and kind of comport to what do we know about this person? So that's, that's what this is, that's how it looks for uh acute teams in our colleagues in primary care. Uh As Karin mentioned, we we automatically send respect plans to GPS and we make that appear within the document system. So again, it's part of the clinical workflow within primary care. As new versions are generated, we automatically send those through and then those can be filed against the patient records of the G P is keeping up today about what's going on without them having to necessarily be, be part of that confirmation. They've, they've been have that information shared with them. So what I was going to do to, to finish with my last slide was ready to talk a little bit about what we are what we're doing now and where we're going with the digital Respect system. So, uh, today we have, we've got five live boards using digital respects. We've got Forth Valley Tayside, Western Isles to freeze and Galloway very soon. Karen, very soon. Uh Lanarkshire, uh, we've got trials planned in Fife and we're working with Orkney and Shetland and also Russia and Iran have started their implementation. So the, the, the growth of respect is really, um really starting to take up across the country. We don't have all the boards making use of the system, but we're seeing more and more that the the existence of a digital system has tipped the balance. So, um respect is just one of many takes a care plan, but it's, it's, it's good enough. And if you have a different digital system, then that can tip the balance and the decision making with, you know, with clinical teams that there's not enough in it. And in fact, we're seeing the respect being used quite, quite widely, not, not necessarily just in the, you know, the palliative care, the bariatric medicine, but actually quite widely across, uh seen as it gets bedded in because more and more people recognize that, you know, having something which is common enough is actually an advantage in itself. So beyond the regional boards, our work is really focused on the National boards and really the unscheduled care services of the Scottish Ambulance service, the G P service and NHS 20 for the, or the 111 telephone service. So these are the places where that this respect information could be used and it's probably his most benefit. And when we survey our users, the use of respect, this is their number one uh request for the system to be able to get that respect information into these systems. And so we've, we've got our first uh toll in that water. So we're gonna, one of the systems that the Scottish ambulance service use the clinical advisers within their uh commanding control centers. They have access to a system called CCS CCS, the web application. And so we're gonna, we're doing some work just now to make the respect information available in that, in that other web application in a similar way to, we made it available to the Lanarkshire Clinical Ports. That's our first step to get it to the Scottish ambulance service. But there's, there's more we can do to extend the information that they have just now to make sure that information is available within the cabs so that the drivers themselves have access to it. And there's, there's more and, and similarly, you know, how do we do the same thing for the out of our GPS? And how do we work with the systems that NHS 20 for you? So these are all national boards. And so us having a national, one, national board, one national system to another national system makes we do the integration once and it's the integrations that are really the 10 consuming thing. So we do it once and all the boards get a benefit from it. So that's, that's one of the ways that we're working on our next avenue of growth is to, to share more widely so other care settings. So community care settings, we we've learning that many of our community colleagues make use of systems like more. So how do we acts get providing respect information to them but also more widely, how within directly within care homes, you know, how does, how does how do we make that sharing? And again, because we're set up as an organization to encourage chairing, you know, between health and care that allows us to um do a little bit more of that. I think there's a, there's a really interesting angle with respect about how we share this information with people themselves. I've kind of talked initially about giving a paper copy to people as their, you know, after you've had the conversation. But the Scottish government has a another program called the Digital Front Door currently. And that's about giving people access to their own health and care information and potentially respect fits quite nicely into that as a potential data source and the information and at the top of the initial part of respect has been provided by people themselves as their conversation. It's their words that are being included in that. So that feels relatively safe bit of information to include back in a patient. I think we would start with, with read only information I think would be a while before we get having people to be able to change their records themselves. But it's just, it's a start. And then I think like beyond that, we can see that the work that the respect information we have is is only the first little slice of information that could be useful. We see there's a growing need to have something like an international patient, somebody which has everything about a person that can be, you know, provided to any of the unscheduled care services could be provided back to the person themselves. Maybe it's the kind of thing that I'll have on my phone that I will carry with me. And so that has everything, all the my medications and my allergies and my problems and the, you know, my wishes and plans have that with me. So that, you know, if I do keel over, you know, that information is with me and is accessible to people who might, who might care for me. And then potentially there's there's additional growth, you know, to other types of careful. And so for example, things like potentially treatment escalation plans, I say this with great caution. This is the treatment escalation plans are not on, are not on our road map just yet. I think we we need the clinical leadership, the clinical guidance guidance to, you know, help that work happen just now, you know, our focuses on spreading what we have to unscheduled care. But it's almost like that's that's uh laying the rails to share information and then as more information comes available, then those rails will continue to be used. So I think we, you know, we will let we will be led by the clinical teams about what's important to digitize and and have that uh you know, have that be part of our platform. So the final side I have is is really an invitation. So we, one of the things I I really enjoy most about working with respect is that is a collaborative as a group of people that we work with. So there's a collaborative meeting which meets about quarterly basis to kind of keep people up to date with respect. So you'd be welcome to come and join us. Please email my colleague for an invite and you know, come and listen, you have to be using respect or have an interest or be having planning to use respect. But if you're interested in, you know what's going on in Scotland, you'll be more than welcome to join us. So I think I'll stop there. Uh Robin and that's okay. I'm happy to take some questions. Thank you. Yes. Uh I'm not sure, but I've noticed on the chats that there are specific questions that I can just immobilize Um Stephen, are you able to help out your this problem? No, there's no questions just yet. Um I was gonna kick off with one in that, you know, it really looks like you um the National Digital platform as a prototype with respect in many ways that will streamline this process. And I suppose we've been chatting about the interface between tepes and respect as an A C P and, and the ability to maybe have a common tepe across Scotland and then work that all together. You know, I suppose I'm wondering what the utopia is here. I always think that Utopia is like, what, what, what, what are we after? Is it a, it's a, it's a digital wallet for many ways for the patient to have all their documentation together and, and everything would run into each other. And so you would have your respect in the community, bringing into Tep and maybe they would talk to each other and then back out again, back to respect and we can use the same sort of platform to do all of that. Yeah, I think that's, you know, you could have talked a little bit already about those bits of information which are helpful to reflect between the different systems that there's different, different information that's captured. I mean, so from, you know, my digital perspective, they're just data points. Uh you know, we, we need, we do, we still need the clinical agreement about what, what data points you want, what is your national tip? So I think that that's a clinical conversation as well. And I think there's, there's, I really like the work that can an allowance. The team have kind of talked about the, the use case about how these two systems kind of work together. And it's almost like the next level of analysis would be, how would they actually work together? What, what data points would you share between? Or, or maybe, maybe there is no overlap at all. And so that, that's the kind of thing. So I don't have those answers, but it's the kind of thing that we would want to work with the clinical teams to understand, you know, how, how, how those to work together. But this gives the, it's, it's very much um the uh it very much is realistic medicine, isn't it? Because it puts it all back to the patient, they own their own data, they own their own information. And then that information is accessible by the ambulance crew, as you said, and you know, if you want to print it out, you can print it out, you could have it on your phone if you wanted to have it on your phone. And you know, it's probably the way forward, isn't it? Um We have um Sarah's made a comment. Um uh It's maybe just the ins and outs of actually filling in the form. Um Theresa says, sounds like great digital system um making it easy to um access information, especially for, for care homes where we're, sometimes you can get lost. Um It, uh it sounds like an amazing process. Um uh Yeah, I think, um uh it's about following that sort of steer from clinicians. And so if the steer is that the two things do different things, then, you know, maybe this is the next thing. Uh uh I, I think Alistair just to um sort of uh give you a whiff. I think the steer from clinicians uh is going to grow in terms of human escalation plans. And the, the, the Lanarkshire model makes them embedded in a complementary fashion. And it would be wonderful if in the fullness of time. Um The Lanarkshire, the Lanarkshire Lanarkshire itself, I'm speaking behalf of Jack and Karen without knowing what they're thinking. But, but, but piloting or, or pioneering the sort of cross talk between tips and respect that I think they're doing in a non digital fashion would be, would be somewhere we would, we would all want to go and, and then, and also with a view to making a national phenomenon just to, for people who are um worried, a little bit worried, are tips. Uh Can we get agreement about, about what should go on a tip? You'll see there, Jack presented a test that's been iterated probably about 17, 19 or 21 times. And there is, I think just to say uh growing awareness of what constitutes the core basics of a tip. And I don't think moving, I think because all that work's been done, moving to a national program or a digital program, which is common to all will not be a difficult task. Um It would have been a difficult task five years ago but, but things have changed remarkably since then. So, but you seem um so we have a break now just that everybody can go to the kettle on or pop to the toilet. Um For um we are, we're running over because as usual, these discussions are very interesting and um there's lots of, there's been lots of great questions and there's always lots of questions that come up more um going to give you 10 minutes. So it is 25 past. So we will get you back at um 25 to um there are breakout rooms um should be at the top left hand side of your screen. If you want to pop in there, you should be able to um speak to each other and have a chat. If there's somebody you've noticed that you thought you might want to have a chat to, it will be able to everybody and some of the speakers might pop in there um as well. So um I'm going to turn off my camera, turned off my microphone. Anybody go up with the catalog and I'll see you in about 10 minutes time. Alistair, Robin Cara and Jack are going to hang about hopefully for the panel discussion, the end or pop back into the panel discussion at the very end just in case you're more questions. So keep your questions coming and uh we'll see you in 10 minutes. All right, bye. So, um, hello again. I hope everybody had a chance to go get a coffee and then he'll a couple of chocolate hot dogs or something similar. Um We have a final speaker today um who is uh Doctor Gregory mcneal. So Gregor has is unfortunately unable to join us um this afternoon um due to other commitments um but he has recorded um a video for us um on what his talk was going to be anyway. Um He is um if you don't know Gregor Gregor is the National Clinical Lead um for Health Improvement Scotland's sp sp acute Adult Program. Looking at the deteriorating patient. He's also a consultant intensive ist in um the Royal Infirmary in Edinburgh. Um He is going to speak to us about D N A C P R. He is going to cover that aspect of it, looking at current problems and uh future solutions. Um So there are also an ability for questions that they are not to Gregor but to the rest of us and we will then go into the panel discussion as well. So I am going to try and make this play and see if the technology works as it should do. And I'm going to speak to you today about DNA CPR current problems and future solutions. As I said, my name is Gregory mcneal. I'm a consultant, credible care here in a chess Lothian, working predominantly the room for me in Edinburgh. Um I um my other kind of probably uh declaration of interest is that I am uh the SP SP lead for acute adult within the health improvement Scotland. And that means I have kind of uh lead quality improvement work within the kind of deteriorating patient work stream. So I have some uh skin in the game when it comes to kind of things like Teppei CP, etcetera. From that point of view. I'm speaking to you very much today with my own personal views on what I see is the way forward. So what we're gonna unpack over the next 20 minutes? Well, um I'd like to really just get you to think about the context about we how and when we make our DNA CPR decisions and you know, the where healthcare is at the moment, I'm going to talk to you about some specific aspects of the DNA CPR form. Once we've done that, we'll just kind of scoop out future solutions and what, what, what, what the future may hold um whether treatment escalation plans have uh show us a way forward for this work and, and, and, and just some thoughts on what, you know, when national guidance is useful when it's not. So my own personal context for this and this has happened not once but twice now is um conversations with taxi drivers. So I don't get many taxis, but I do often if I'm going to the airport and someone else is paying, I will get a taxi. And on two occasions, on early morning, 12 up to Edinburgh airport, I've had a conversation with a taxi driver and, and they've said, you know, what, what you do have sort of a, I'm a doctor in intensive care. There's usually been some chat about how, how tough the pandemic was and then it goes on and it spills on and the test driver says, um, do you know why my mom was called up? My mom was called up by a healthcare person and they were told that they wanted to make them D N A R and I was shocked and my mom was shocked and we were disgruntled. We were unhappy, same kind of conversation again a couple of months later. And that made me think. It made me think that these conversations aren't always going well and we're maybe trying to do something that's just not working and maybe it's because we're trying to have the wrong conversation. That's not necessary what we're, what that healthcare worker was calling up the mom to really discuss if they really thought about it unless I'm tired a little bit more. And certainly the conversation left that patient and by extension, clearly, her relatives feeling that well. Actually, the healthcare system doesn't care about me. You don't care, just want to not do something. And why did that conversation not go, go well? And it may actually be that actually the reason that healthcare worker was calling up, that patient was sure they were in actuality asking about DNA CPR. But actually they were doing that because they wanted to use that decision as a surrogate to decide us or other stuff. So the conversation wasn't really joined up. Let's unpack that a bit more. We all know that uh our healthcare systems under are under tremendous strain right now, unprecedented strain. It's almost impossible. We all noticed to get appointment, our GPS, my wife's a G P. So I can say that um if we get seriously ill, it may be a delay in the ambulance getting to us once the ambulance arrives and we have to wait in the need before it can unload us. When we sit in the emergency department, we're likely to be sitting in a trolley or we may have to wait something in my board upwards of 40 hours routinely to get onto a ward if we need admitted. So clearly, the healthcare system is under strain public feel that um and, and uh and people I think genuinely worried that we're having these conversations because we're trying to uh cut them off. Um And that's obviously not the case, but why is the conversations we're having? Not, not the right ones. Well, that, that, that's something we need to think about. Another aspect of this is um expectations because on one side were telling the public overwrought we can cope. But another side of us, sometimes it's coming from the same people in a difference that they were saying how amazing healthcare is and what we can achieve and some kid weighs healthcare is a meeting what we can achieve with modern techniques. And we rightly want to show to go to as we try to advance clear in, in very challenging circumstances. And it's been known for a long time that patient's perceptions of what can be done um in some ways are very different from, from reality. Um There is a paper published in 1996 which shows 75% Roscoe uh for um cardiac arrest displayed in uh and in, in T V dramas. It's not uncommon to see the patient waking up and sitting up quite a thing afterwards. Even if we look at the published evidence around reality TV shows relating to healthcare themes, everything is very skewed. You're far more likely to see a traumatic cardiac arrest. Your farm would like to see trauma per se. You're far less likely to see what the majority of arrest that we see and uh the outcomes or seeing care delivered such as CPR to a frail population where it may not benefit them that is not really covered in um in media. No, and the evidence would support that. And we rightly want to shout about the things we do that are amazing. And there's a lot of amazing stuff out there. We were very lucky to work in healthcare. You know, the reason why I'm an intensive care consultant is because I like delivering complex therapy to save lives. And you know, this picture here, this is um you can probably see that this is the Eiffel Tower. This is a picture from last week. Um The this involves a patient who had uh resistant VT uh with loss of output on the middle deck of the Eiffel Tower. And um the SAMU team, the amount see team in Paris came, attended to the patient. One of the doctors who seconded doing um an educational secondment with the team is our very own, Doctor Hartley, who those in Glasgow, uh Edinburgh and Aberdeen May. No. Uh Doctor Hartley is a consultant in the Royal in Edinburgh. And that is uh Doctor Hartley and a colleague placing that patient on ECMO E CPR successfully patient transferred to local hospital. Three stents later, the patient wakes up. That is amazing. That is, that is amazing. It uh it made the Parisian local news that, that he think and um you know, the public see that I think they can really do amazing stuff, but clearly this is a very specific situation a very specific circumstance but you can see almost as a relative or a patient. Remember the public, the confirmation bias. This is going to give you this. Oh, my goodness, they can do this for me. And I have my, am I uh, some years from now and it's gonna lead to confusion, confusion of our patient's, uh, confusion for their relatives, but possibly the main problem. And I kind of slightly alluded to this already. The main problem with our CPR, our DNA CPR farms is it's not an honest discussion. We all know as healthcare providers, once a patient dies, that is generally it, they are dead. And we all know that CPR um is not very effective unless it's a specific circumstance, you know, in CCU post M I highly monitored environment, then it may help but largely it doesn't. But we're using that D N A C P R form as a surrogate to decide other things. So we're not really having an honest discussion with our patient's. The reason that there's such a push to do DNA CPR forms is we really want to know what, when are we going to be offering these patient's advanced therapies such as admission's critical care? When are we going to think about antibiotics? When are we going to think about instituting palliative care? When are we going to do invasive things like CPAP N I V invasive ventilation are tea, all that stuff? That's what we actually want to talk about, we all know as healthcare providers, once you're dead, you're generally dead. So the premise of taking that form to a patient entering to that conversation is, um, it's not, uh it's not necessarily as honest and as clear as we could be. And we need to get clear information. Now we go into these conversations because we want to create a treatment escalation plan. But I think the form is, this red form is pushing us to have a focus on DNA CPR breath. Actually, the other stuff is far, far more important. So we focus the form makes us focus on this act, this act that we do when a patient has died. And actually what we need to focus on is not the bits in that form. It's the bits and the treatment escalation plan because these are the beds, the harms or the benefits. We can give a patient in life that are more important. We want to think with the family, with the patient about whether they would benefit from noninvasive ventilation. We want to think with the family and the patient but whether they benefit from invasive ventilation, feel care admission. These are my biases. But for you working award, it maybe are they going to benefit from antibiotics? Are they gonna benefit um from palliative care. Should a deterioration occur when that's what the conversation needs to be about? What you know, who cares once they have arrested and died. Um That may need to be referred to at some degree. We may still may need to make a decision about that, but it should be a tiny bit of the conversation. The least important about the conversation, you could argue. So we need to be uh as honest as we can be because we all know that once kind of crest occurs, the ship has sailed. Um And, and therefore that conversation is the least important. Bet it's what are we going to do for this patient in life or the benefits we can give that patient in life or the harms that we can avoid in life and everything we say and everything we um develop and, and put out there in, in terms of the health improvement, Scotland SP SP is about being as patient centered as we can be. And the patient centered conversation is about the things that we're going to do for that patient uh when they're alive to avoid homes and when they're alive, clearly, CPR can be harmful to a body. It is great in dignity. We, we also want to maintain a mechanism where we don't start to do that inappropriately. But if we focus too much on that aspect of care, we risk generating harms in life. So where do we go from here? Well, um I in my role within SP sp very lucky to have been able to chair the update for the sign one to be nine guideline dealing with care of the deteriorating patient. Some of you may have seen that it's been out for consultation, that consultation is now closed. We hope um that uh this guideline will be launched and published uh mid mid June this year. Now, um I can give you the the details of, of, of all all all the details of this document clearly at the moment until it is published. But I can say to you that it will cover primary and secondary care and it will make clear recommendations about the use of tep and anticipated care planning. And we'll also comment on the use of uh D N A C P R in that context and, and we hope that will be useful for all because what boards have to do is consider sign guidance and what the wider healthcare system has gone has to do is consider sign guidance. So uh watch this space on that and I'm sure I can't share any more detail on that at this moment in time. So, so that's the context. So hopefully, um I persuaded you that there needs to be some uh some change in emphasis. But what systems do we have in place already? Well, actually, um there's a lot that is good in terms of the processes we have in place because um many healthcare systems across the world do not have national guidance. Um Complete national guy counts on decision making regarding uh D N A C P R, they do not have one single form. Now we do. Um And this is, it, it was published first in 2010. It was actually based on NHS Lothian's uh DNA CPR integrated Adult Policy, but it went national and it was updated further in 2016. And many healthcare systems think this is a great thing that we do have that 11 form for all. And we have National Guidance and it was produced by the Scottish government. But I think you can see from what we've we've discussed is that that conversation now is just far, far too narrow. And the risk is if we focus too much on daily A CPR, we forget the others. And I would argue more important bits of a treatment escalation plan or an anticipated care plan and the continuation of this form. And it's now is narrow focus. Uh It does potentially risk harms and is out of step with our patient centred approach. So I think we do need to think about changing that approach and, and, and reducing the emphasis on the DNA CPR form and moving over to a treatment escalation plan uh for such as one here produced by uh Greater Glasgow and Clyde because this is the conversation we need to have. This is the key bit and D N A C P R is just, or, or for CPR is uh just a small, um small part of that Uh And actually I think what the more, the more challenging question is about how we do that. Um And that gets the debate about health delivery or generally, is it right to have a single form for every board to use on a single policy or is there local nuance? I'm not going to give you an answer to that right now. I think that has to be picked out and the conversation has to be had by uh people from different perspectives. There are some strength in having one form for everyone. Um But people do have different opinions and contexts are, are different. So um there is also uh benefit from having a local Newell's, as you can see on the panel on the left there, we've got a variety of uh tech forms. We got the track version from NHS Lothian Great and Glass of Clyde. One. Um Anxious Grampian uh moved across to attract care based one as well. But that, that is a, a previous version of, of a tech form used NHS Grampian. So I said, I do know, but um uh we do have a national guidance around um a daily CPR form at the moment. And, and I think that that is something that we need to look at and it may be that uh there has to be guidance around national use of the TEP but not a single tet form that can be decided at local level. But these conversations have to be had. Um, and I'm sure I'm sure we'll be had had in, in due course. And I think what we're all trying to move towards is care that it's patient centered. And, and I think, um, it gets back to that honest conversation. What is important to the patient, what is important to you is the healthcare provider. The important thing is that I have a honest conversation and these can be difficult about the important bits and the most important bits are what we do to patient's in life, not what we do to them once their heart stopped. Uh If we focus on that, I think we will deliver better care for our patient's. And I would argue a more satisfying experience for healthcare providers as well. I'm very sorry, I can be with you today to take questions, but I hope uh you've enjoyed the presentation. Thank you again. Hello. Um So we had that excellent talk from Gregor and of course Gregor um cannot be available today um to join in. Um We have uh the panel back again. I think maybe Alisher is going to join again. We have Karen and Jack and Robin and I think we might actually uh we have Dr Calvin Lightbody in the audience as well. I'm going to see if I can fight him to this stage um as well whilst that's happening and um Calvin can maybe joined in. Um I shall um look to see if there is any questions that are coming through. Um I'm reading Darius is question here. Um What is your view, your stand on critical patient that has been managed aggressively um into cardiac arrest, revived GCS three um cleared by the intensive is to continue palliative care at home since they were informed with poor prognosis. Um um uh fighting functions, family retract, do not resuscitation orders. I think that's maybe a question about patient's going out into the community. Um So actually, I may be going to segue into that question. I was going to ask Karen and Jack that I kind of set up and give them a bit of time to think about, about uh that interface um with primary care and um what the team in primary care. Um think about that. And then actually, so then we have got Calvin as well who is uh E D consultant. So we can um get an idea of uh coming the other direction and maybe doing this back to front into the front door of the hospital. Um And, and that is the case as well. So Karen and Jack, yeah, thanks. So I think in an ideal world, I think you would imagine a situation where I might admit a patient that you see them and, and a post take ward round. Uh junior doctors already started a prognostic conversation, initiated the tip and I might countersign that and evolve a conversation with a family patient survived the admission and uh as they come to the end of the admission to get respect for him and go home, having your shared decision making with clearly established goals of care. Now, in, in my practice, I see some of these patient's coming back, you know, they might have been on the renal ward and then I see them back in a, in a renal clinic and I might revisit conversations, you know, I've got a patient to last summer actually was acutely ill with hyperkalemia. We decided that renal replacement therapy wasn't in her interests and managed her much more conservatively and she actually survived. She has ongoing issues with heart failure and various other call mobility and it's increasingly frail and we've had an issue where we had a clear plan that she was going to go home in a fairly palliative and pragmatic approach and didn't want to be re admitted to hospital and she's had four further admission's to hospital in emergency situations. Um Some of which prompted by her family, some prompted by out of hours primary care and some I think was a recall by the labs, you know, with hypercalcemia. And so she had three or four further unscheduled admission's and I saw her again in clinic recently and actually, she reflected that on balance while she hadn't wanted to be admitted previously, she was quite glad that she had been because she'd survived and she still had a good quality of life. And so we revised her Respect ACP at that point and said that, yeah, at this stage, she was reasonably stable and wanted to be re admitted and, and the, the hope would be that there'll be an evolving kind of a C P documented on Respect platform. I would love it. If in primary care, the patient, you might have seen their GP and had another conversation, you know, the GP might then update a respect formin realtor it in real life. And then you come back to my clinic and I can see that that kind of two way dialogue, that communication clearly there and still all ideally owned by a patient and their family who are able to access it through the envisioned envisioned front door. I think that'd be great if that works. If it doesn't, I think there's still value in these iterative bits in the, in the meantime, even if it means that when this patient arrives in the emergency departments and she's got a potassium of 10 and Calvin is looking after, he knows where she's been before, what the conversations have been. And he knows that, you know, we're not going to be rushing to put analysis line in where, you know, and if she's at the point of coming to the end of her life, she's gonna be in a side room and any, even if that's how she's ended there. So I think we're getting there. I think we're making progress. Hopefully, as these bits gets simpler as the, what was it Robin put, making it easier to do the right thing. Hopefully, it means that the GP that the Renal consultant, the Fy two can all update these things in, in real time and evolve those decisions for the patient's between primary and secondary care easily. I think the respect platform will allow that fingers crossed. And what's your impression of your primary care colleagues um feelings around um advanced care planning and uh and, and this sort of even this interface. Um And, and if there's anybody in the audience um from primary care that has got any experience of this, wants to ask a question, make a statement that would be excellent as well. But um yeah, so I think, I think I've had a number of conversations, I don't have any formal data to back this up and hopefully that will come in due course. Um And I think uh an interesting point was put to me by a GP. Recently, we, they didn't feel that they were in a position to judge whether or not someone would benefit from going into hospital because they didn't know what hospital could, could offer. And I thought this was a bit about a bit like when you discharge someone from ICU Stephen and make a decision often at that point about whether or not you would or should readmit them and re refer them to ICU. And I think we're really bad at that in secondary care, having a conversation, making a decision about whether or not hospitals got much to offer and then communicate, getting that to the GP. And yet I know many secondary care colleagues who cursed the out of hours GP for sending patient's who are clearly on their deathbed on the way out. And I don't mean that pejoratively but clearly you could imagine that they were coming towards the end of the life and you're surely wouldn't gain overall benefit by being in hospital. And yet your why are we not communicating this in the opposite direction when, when we feel that when we're discharging patient's from the wards over and over again. So I think that definitely is a role for us in secondary care, getting better at um communicating our views about the benefit of future hospital admission's. I think we also need to realistic certainly where I work where we have the lowest GDP per head of population, we can't really imagine GPS of the time to go out to patient's houses and spend an hour having anticipatory care conversations with people who've got, you know, heart failure, COPD and, and kidney disease. I'm not confident that that's always reasonable to expect GPS to have that role and to expect them to be able to do that an acute crisis when they've got 400 other patient's needing decisions about admission that day. Um I think secondary care needs to own a lot more of that is my own view. I think if I was, I can't certainly speak for all our G P population in Lanarkshire. But for those GPS that we have been working with, um they are encouraged by the respect process. Um and, and particularly in the viewpoint that again, it's a multidisciplinary approach. So therefore, it could be the district nursing team or the advanced nurse practitioner who's involved or in fact with the pharmacist as part of the multidisciplinary team working in the care homes who have initiated the conversation. So that that's where they're seeing the benefits unlike wise, um you know, it's reducing that element of angst where um as part of the discharge plan, you're informing our community partners um on what has been documented and it's being shared openly unlike wise. Um The hope is that there would be that iterative review. Interestingly, I had the opportunity to attend a Warwick University for the NHS England stakeholder um review around respect. And that was a consideration that they hadn't built in in the implementation was around the review process. Um And with that, there was an element of, of digital envy because with the digital application of respect at any healthcare interaction, you have the opportunity to review the respect and refresh it depending on the the outcome of that interaction. Um So what they did introduce in England was thinking around their patient's with long term conditions, etcetera, where they can build in an annual review, the GPS within the East Kilbride Locality. They've started to, to introduce the respect process for those patient's with long term conditions, with life limiting disease and with frailty with whom they have interactions with. Um and that's the initiation and for all of their care home admission's the respect process. So it's enabling the growth of it, but we're by no means obviously fitting the full population of Lanarkshire yet. Yeah, I think I um one of my colleagues and another renal physician um had something similar where she had a conversation, a clinic with a patient about uh MRI Ambition um and had written large part of her letter about that, but then um met the patient on the ward again um like a few weeks later and they were both sort of surprised the patient had gone along with a wave of coming into hospital Aloe and had never really been asked what our opinion was. Um And, and so that process had been lost. I think that goes with um you know, Ian has put a statement in the chat here about pushing for a national MDT section for a complex diseases by prognosis of conditions. And I think that is that specialist in the area being able to communicate um thoughts about the patient going, going forward. Um um And you know, what might be um as um Robin has put in the chat as well up and benefit for the patient uh as, as, as opposed to anything else. And Calvin, if I can bring you in for the opposite way around, um coming into hospital. And what's your, have you any experience of ATPs coming in with patient's to E D? And um you know, have you introduced um, well, I kind of know that you've introduced tips into E D and, and how that functions in your department to be really interested to hear about that. Yeah, thanks to uh my experience is that there's lots of patients come in with an A C P which is either the s the electronic information summary or maybe some kind of handheld piece of paper. Generally speaking, without being overly general, most people want to be staying at home. Most people don't want to be in hospital and they certainly don't want to have their end of life care and hospital. But the reality is whenever appearance, patient's experiencing some complex symptoms, maybe towards the end of life or deterioration in their situation, the phone 999 and there's a whole cascade of events that happened that they end up in A and E. So even if they've made a clear plan that they want to stay at home and they want to die at home, they still end up in A and E. Now, I would hope that in the future that respect is more widely utilized that those conversations happen. But the the the aspiration that comes with that needs to be backed up with resource until those things happen. Then I think we're going to continue to see that situation. For me. The, the key thing is context whenever a patient comes in uh in a situation where the context is one or multi morbidity or frailty or some kind of trajectory that suggesting that end of life is coming, that we then initiate the treatment escalation plan at that point. And certainly that's been the practice in the emergency department where I work in manic shirt for a few years now. Certainly that's not an easy thing to initiate. I know one of the questions about A C C award where there's a difficulty Joanne Murray has mentioned that her question about getting medical staff on board. I can very much relate to that there needs to be a culture change, uh an award or a department or service where the culture is that we recognize the context of each presentation, we're mindful of the consequences of escalation. And we have that conversation with the patient in their family and that honestly uh is what it comes to the fore. So yeah, that's the current reality is troubling. Uh more optimistic, I guess if, if patients come in and I can see on their mechanical portal or the paramedics, even, I think they would really appreciate being able to see uh what Ulster's describe that the visibility of a previous discussion that's going to really help me and my colleagues in the emergency department to make a realistic, honest and practical plan for the patient. Um Alistair, I was just thinking and I'll make it come to Robin with another question afterwards. But um in terms of the digital platform, you know, how much control does a patient have over it? And can a patient go in and adjust their own respect form? Um then kind of make a decision or does that, you know, um is that sit with a healthcare provider to make it along with the patient? How much does the patient own their own information? So today is, is all done with the health care professional. That's, that's, that's how the, that's how the information is captured and recorded. It's only healthcare professionals that have access to the respect. Uh But we could see within, I think almost within the next year that potentially people could have visibility of the information that's in their respect plan directly to them without need to go to clinician. I think that would be a, that's like the first step would be a read, only read only view. And then I can imagine within the next couple of years, potentially we would be moving into um potentially people being able to contribute to their, their own records. I think we would see like respect, you know, has a number of different parts to it and some of them, you know, for example, there's a whole bunch of stuff about clinical recommendations so it would be inappropriate for patient's to be able to change those kind of things. I think there's even something like respect then triggers all those difficult questions about what, you know, what should a patient be able to change or not? I mean, things like changing, even things like changing name and address, it might seem like, you know, useful services or digital system to provide. But there's a, there's a big knock on impact for our, for the system. So I think like that, those are the kind of questions, not, not just what, what could the, what would the people find useful to do, but what's the, what's the impact on the bigger system and what, you know, what should they be allowed to do or not? But it becomes more feasible with digital. These difficult questions still have to be addressed. Robin, um, the engagement of medical staff again, um, comes up and I guess to everybody, um, any top tips for, for them. Well, I think if I had, if I could give you top tips that worked consistently and fast, then I would have relinquished this role many, many years ago. Um It's the toughest bit of the job. Somebody's, I'm just, I'm just going to post a chat response. Uh, because there's a, there's a question, maybe it's the same question you're trying to address about. You know, the, so Joanna works in a CCU and the cardiologists are a bit reluctant that is with deep respect to my dearly beloved colleagues in cardiology. You have Karen asking the same question. No, great surprise, get surgical consultants to engage as well. Well, well, it is culture development and I think we're back to chicken and they were back to carrot and stick. I've spent a long time on the carrot and I think we have to be gritty enough to say uh particularly M and M's, I was discussing, we were, you know, Stephen were developing this in Grampian and we had the discussion with the M and M coordinator in Grampian just yesterday. And the she, she was bemoaning the fact that consultants select who is to be discussed at an M and M meeting. So therefore, it becomes a focused, focused on technical interventions. And if it was, if it was, if it was Jack, they're out, Jack would be choosing um I mean, implying onto you, Jack maligned objectives, but you would be choosing all the analysis, the dialysis people who have done really well and gone on to transplant and, and then maybe had a tragic death because of immunotherapy that gave them an infection. And but, but you see, so there's so this is the stick and I actually believe we have to get real about this. Harms are wrong. And if we recognize that harms are wrong and my decision making has been a contributor, there should be a degree of humility involved in that and a willingness to reflect and learn. And so back to the discussion yesterday in Grampian about M and M's a non, a non selective approach to the ones that are selected. And you might say, right, we're going to do willingly every 15th death in this hospital we're going to look at and we're going to ask irrespective of which consultant and irrespective of how they died where the decision making process is consistent with values based medicine and realistic medicine. That's where I was going to in one of my slides. Then there's the very crude way of doing it. And I can't tell you this is done very often, but there's the league table stuff. So you have a unit with 10 consultants and they're all labeled A B C D E F and so on. And that once a month or once every three months, you put up a list of how many tips there were against consultant, a consultant, be consultancy and consultant dean. No, we're such were such adolescents in deep down that we actually respond to that. We say, oh my goodness, I only had two tips last month and Jack had Jack had 17. And how can I change that? Because I really don't want to be at the bottom of the league table. So there are some things that we can do and I think we need to be firmer encouragement. Every I know that encouragement is the place you start. When you're trying to initiate change and you do it patiently and your reward, your reward, what is good practice? But we think, I think we should on this one, we should reflect on what is bad practice. And bad practice isn't defined in some of the terms that historically, we've been used to judge it, making a judgment, bad practice for a surgeon. Remember the Bristol inquiry regarding regarding cardiac deaths, a cardiac surgical deaths? Well, some of the things that we're used to judge individuals were entirely technical and clinical. Now, I venture to suggest that that sort of judgment would have been different in some respects if the when you shift back and say well, okay, the patient went for a valve replacement, was that going to improve the quality of life? Should the decision had been made in the, in the first place? The that that wasn't the answer and I was going back 20 years. But the question is being raised was where the standards of care about how you replace the valve up to scratch. And what was the post operative care like in the I T U? And you see, uh so I think there's carrot and stick and I think we need to be building in a reflective process which is independent of the consultants view of what's important. Because at the moment, we still are steeped in the idea that fixing the problem is always the number one priority. And that is tough because I've been, you know, I've been practicing for 45 years. I was steeped in this when I was a younger doctor and I don't, not sure I've recovered from it. I'm glad to say some of the younger generation are recovering from it and they need encouragement to do so. But the incentives need to be more than just you're doing a fine job. Thank you for that. Thank you for filling in the tech. I think that the whole movement has to be towards an accountability that is not blame, blame finding, but a reflective process that then ends up with a shift in the culture. Sorry, you've got a little speech for me, but there you are, I wonder if I could just make 22 points. First of all, I suppose is to the couple of questions they're in the chat. I personally feel very much that this should be an empowered MDT approach. I think that board rounds and other kind of structured ways definitely have the role, but there is nothing more powerful for me than an experienced nurse approaching me. And you'll say, what were your, what we're doing here? This person is clearly dying. Your and I find it much easier to make decisions about limiting therapy and about setting uh ceilings of treatments. When I know I've got an M D T backing and So I, I, I think it's really important part of culture changes that we get used to having these conversations and being frank with each other. Um I've had it much when experience renal nurses. Tell me that, you know, this person clearly shouldn't be for dialysis. I find it much easier knowing that they've got, you know, decades of experience and, and they, you know, their opinion is really valuable. I think it's worthwhile them saying that whether that's a board round on a ward round wherever I think people speaking up and, and challenging consultants who are either making a wrong decision or making no decision. And actually, you're being clear about it. One of the charge nurse is where I work depending on who's which consultant she's working with has a great habit of just taking the blank tips and sticking them in front of the note. Uh at the beginning of the ward round, you see a whole row of tips eagerly sticking out of the patient's folders waiting to be filled in as a, as a not so subtle hint that this needs done. And I think that actually is surprisingly effective. The second point I want to make is actually to play a bit of devil's advocate and to challenge Robin away. But there's a point I made it when I was talking is that a tip done badly is worse than no tip at all. And I worry a bit that when we focus purely on the numbers and we, and we encourage people to do tips all of the time. The default I see over and over again is people filling in a tip but just documenting for full escalation when they've got it, you know, and when, if you were properly looking at this, you would say actually you've just taken the easy way out there. You don't want to have a challenging conversation. You want, you don't want to diagnose dying or uncertainty, you're just documenting the default, which is full, full escalation. And I exactly in the medical registrar at three in the morning where you come along and esteemed consultant has been encouraged to fill in the tip. They've written full escalation and then I'm obliged to put in lines and put them in HD you and phone Stephen to call for my ICU help and that really gets my goat. And actually, I would much prefer it if a prognostic conversation hadn't been, had a tip, hadn't been done. And I was able to come in and do what I perceived to be the right thing with the support, the consultant at home as a med reg then and be able to establish goals of care, then I would prefer it if they were establishing the day properly. But in lieu of not being done the right way, I actually think there's a risk of over doing tepes if it's not going to be done properly. And I don't have an answer for that. Other than saying, more of us as consultants and senior clinicians should be practicing strategic medicine being clear about what our goals of care are and, and having those hard conversations. But yeah, I, I think Calvin's points about all the wise consultant tell themselves are 100% true. And yeah, that's one of the challenges we're up against. Well, Jack, you've just highlighted the tension and the imperfection of the whole system which will never be resolved. But I take your point and I'm quite happy to be openly criticized in front of an audience of however many. But uh um I, I think one of the things for me and then goes to what Calvin saying there is that I hear that as well that um we're too busy. We don't have time to do this. Um But I think it's time that generates a lot more time at a different point further down the line and kind of interested in Calvin now. Um you know, E D is one of those places where time is time is gold. You guys don't have time. The other thing I suppose from personal experience is um I can also or we, we have a digital um TEP in Grampian now and the back end of it, we can look at the number filled in and we can match that against the number of D N A C P R s filled in and there is still at the minute, a big gulf between the two and my point there would be if you are having the conversation about the D N A C P R, the conversation about the TEP can be built into that and to bring that TEP line up, at least to the D N A C P R line would, would be achievement in itself. Calvin. How do you have these conversations um when it's so busy, I think the fact that it's, it's so busy, it is not really an acceptable excuse not to, to, to make the time investment for a particular patient. I guess the other thing about that is what's changed now from about five years ago is the fact that patient's are in any for a lot longer than four hours and the patient's in, in my department for a day, maybe even longer sometimes. So we're actually looking after these people for a lot longer. So the argument that isn't time just doesn't hold water for me. Uh We need to accept that their, their harm comes to patient's whenever we don't engage in that conversation. I thankfully it took a while, but certainly my colleagues are very much on board with this. Uh The senior nursing staff in the department are, are, are very much involved with that as well. Uh The patient's who really need to have a treatment escalation plan established at the point of admission, do get that done. Uh The other issues about, you know, maybe it should be done further down the line, we should be done while the patient's been assessed. And you've got a bit of an idea of what's happening. And I've heard that argument made, but again, it misses the point that the patient's escalation at the point of admission is key because the patient might be seen by four or five different doctors or conditions further down the line. And what you do at the start very much sets the tone for what happens later in the admission. So if you start off the aggressive escalation that does tend to continue. But similarly, if you take a step back and accept that this patient's frail and that aggressive intervention simply won't work, you very much set the tone for the for the rest of the admission. The idea then that this is a difficult conversation. Is this something that's uncomfortable again, I think doesn't hold any water for me. It's something you just need to do. You need to get comfortable with doing that. There are tools like red map to help. But what I use repeatedly is I want to focus on what is going to work and not do things that won't help, that won't work. And whenever you turn the focus around and you're talking about things that might work rather than some nebulous concept of an intervention that's got really no chance of helping and that you remind people that you're certainly not giving up quite the opposite. You're changing the focus of care uh to keeping their loved one comfortable or explain to the patient that's a particular intervention would be painful or harmful or, or undignified in some way. And that works. And it's really one of the most rewarding parts of my job acts I think is whenever that conversation happens and it goes well on a patient movement, place of anxiety or fear of trepidation to one of acceptance. And that's true of family members as before. So this notion have been too busy or the chaos of any is not the place to have. This conversation just doesn't stack up. Uh And as I say, I think working consistently uh to change culture brings great rewards. Um Excellent. We have about four minutes left. There are no other questions really appearing. Um As I say, that is Connor. Um uh it's in a good statement there. Um I have um been encouraged to hear about the implementation elsewhere. Um uh It's been uh I think like any change that you're making, it takes time. It's small steps. It's um um incremental gains, isn't it? Um And you, you, you get there. Um You bring your colleagues on board, you see the small winds, they see the small winds, they see the benefit to vacation it flavours what they do going forward as well. Um I see how D N A um sorry, Tepes and a CPS can work together. I see how it works in with D N A C P R and having that conversation. And, you know, we're chatting about doing the right thing for um the optimal benefit for that patient. Um As we go forward, I can see the, the tools that we have and the, the important work that Alistair is doing to bring those tools for clinicians and for the patient's together. Um And it's, I think it's very encouraging. I hope everybody else has seen that I might give you all a, a minute on your thoughts. Um And then we'll, we'll be just wrap up at the end. So uh Karen and Jack, um any, any light bulbs to take away, I don't know that I've got a light bulb and if there was, I would be grasping it very firmly from the colleagues in this session. But I think there's an element of reassurance that um where there's challenges. Um we're all having similar challenges and, and having more of this type of event where we can share and, and be open. Um uh in order to, to lead on from this, I think is very helpful. Um And also to hear from a kind of national perspective because I think where we have more of that national approach and shifting away from individual small pieces of, of work um that may not cut, cut the grade. Um So I, I think having more of this has been really, really helpful. Um And particularly I've got a few take home points for, for me going forward. Yeah, not a great deal to add. I think this is a really exciting stage that rat I think, step and anticipatory care and all of these kind of discussion's, um I've been through a real journey over this last decade and, and the recent kind of digital and technological advances. I think it's a really exciting step. I'm thinking about linking in with primary care and secondary care and just making, making it easier to do the right thing. I think we're a really good um stage for that and, and, you know, just the number of people in a meeting like this and the enthusiasm and interest is, is really reassuring and exciting for me. So, yeah, thanks very much for the opportunity to, to come and chat about something I'm very, very excited about. Thanks Alastair maybe is the non coalition in the room. Um Any any like build any things you've taken from this? Uh We can do this. It's just thing, you know, be, be positive, you know, the, you know, you've got all the tools, you've got a good agreement, you're moving forward, you got evidence to prove it, we can do this. Excellent. Thank you. Um And Calvin, you were in the audience for most of this listening in um to all the different talks, um thoughts from your expected Yeah, just, uh, to make the point that the best person to have a conversation is the person with the patient, whether that's a junior doctor, a nurse, uh, paramedic. I think that whoever is with the patient at that time and dealing with and they're the best person to have the conversation and now we've got the tools I think to, to do that. And I'm really looking forward to those tools, all these acronyms that we've had all pulling in the same direction and being visible. Uh I'm optimistic but anyone who's on this call is wondering about who's the best person you are? Thank you, Robin. This was all your idea, run this webinar. So you get the final comment. Well, I, I couldn't be more encouraged. The fact that over 200 people have registered, I don't know how many are actually online, but it doesn't matter. We, you and I thought there might be 30 or 40 at most. Um This is, this is here to stay and is here to develop. I got really discouraged. One or two people I can sense in the audience are feeling there at the early stages and they're feeling a wee bit flat or a bit discouraged. And I felt really flat in 2006, 17, 8 after doing it for two years in Lanarkshire, and I was seemed to be getting nowhere and then there was a sort of, I would not call it a tipping point. I call it a tipping point. Um There was a change. So I've only got three words to those who have discouraged. Never give up, never give up. Because if you do, you actually give up on your own ideals and principles and if you give up on that, then you may as well change your job. So, so don't give up on this. It's really tough. It's complex, it's difficult and we're in a very difficult environment but it, but it's it's really worth working on and worth pursuing and remaining faithful about over months and over years. And that's well, my closest colleague in this is Calvin because we worked together now for six years, seven years and Calvin would reflect in exactly the same way on the the idea of persistence. So there's that it's worth it. It's worth it. Yeah, I am totally bought into this. I see it as the future. I see it as the the right thing to do by our patient's, their families, their cares. Um I think it's the right thing to do by or colleagues um or, or junior doctors or nurses or allied health professionals, I think um it is important. Uh Steven, may I just add in a practical point, those of you who have registered, you actually have access to materials here, but you've also access to some of us have been doing it from a long time and we were not precious about the resources we have developed or are developing and that's true in Lanarkshire or Lothian or, or Grampian or wherever. So I just want you to say if any of you want to flick an email and get some of the materials which might enable you to follow this up and follow this through, do do get in touch and we'll be very happy to respond. Um Yes. Um we will add some additional catch up content. Um We've had 240 odd people register and the number of those people will be catching up in the content that the videos will be available of all the talks. Um I personally just want to thank all our excellent speakers. Thank you for giving up your time. Time, time is, is that is golden, especially nowadays. And the fact that you've been here for a number of hours in the afternoon has been excellent. It's been very informative. Um And I thank the audience for asking um lots of good questions there as well and I hope you've got something out of it. Um We have a feedback form that we will send out to you. Um When you fill in the feedback form, you will get a certificate for your appraisal CPD uh fridge wherever you want to put your uh certificate of attendance. Um We have run one of these already. We may plan to run a few more. Um And so that feedback gives us an idea of where you want us to go with that and, and adds um things in um like thanks to fill and especially Sue Gibson Medal who have helped us host this event and um the metal platform, the discussions, we've had our free too um other healthcare providers in areas where it's maybe more difficult to access this sort of continued learning. So I think there's a really good ethos behind that as well. Um I mentioned the Y and the war and the how of treatment escalation planning at the start of the webinar. I hope we've given you some insight into it mainly the how. Um and I think you can use this to empower your patient's um their families, clinicians and uh and, and hopefully, um you know, doing the right thing as Robin I said, making it easier to do the right thing is very want to go. So just thank you very much everybody again. And uh yeah, we will um hopefully see you again at another webinar, but I shall say goodbye and uh have a good afternoon. Thank you. I shall get the Percenters to stay though.