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or next Speaker? Yeah, we're just going to put on his camera. There is a doctor, Calvin, like body. So Calvin is a consultant in emergency medicine in a Myers as well. He, uh, probably still has an interest in, um, palliative care. Um, any papers on treatment? Escalation? Planning? You will have seen calcium on a number of them, cooperate with Robin and others Believe you have also a series of podcasts that you've done on treatment, escalation, planning. And, um, you have many years of experience of implementing people escalation plans. You have been doing this, Robin, help me since 2016. Yeah. So that is true. Um so, Calvin, go to chatters, um, about implementing plans in the e d. And how to get staph on board. Okay. Thanks very much, Stephen. Thanks for the introduction. And thanks to yourself and and Robin for inviting me long to to talk about this subject this afternoon, As you mentioned, I've invested quite a lot of my professional time and energy and to making treat investigation plans work in an emergency department for the last few years, Uh, an ongoing challenge in the emergency department, and indeed, in the wider hospital where I work. It's just learning, Sure. So rather than talk about the nuts and bolts of making a treatment of escalation plan, I thought it would be more useful at the time. I have this afternoon, uh, talk a little bit about my experience with getting treatment, medication plans to work and some of the challenges along the way. I think that would be more useful thing to talk about. So I'm going to focus a little bit about upon some of those bumps in the road that I've had, uh, some suggestions how to deal with that based a lot of this on some of the questions that were already coming through for people have registered for the course, so hopefully that's helpful. Hopefully, that's what people have in mind for hearing this afternoon. So let's jump in. I'll just kick off with this. I think that's a really important thing to have. If you were somebody who's wanting to bring tips to your place of work, whether that's an E d and h do you like to or whatever any kind of acute place. This is what I think you need. First, I think you need a vision for your department first and in the blue box. There is a an example of the vision that I think would fit in here but endeavoring to provide a realistic medicine approach for patients if they're likely to be in the last year of life if you're not familiar with realistic medicine, it was an initiative from the Scottish chief medical officer a few years ago, and it's based along ethical principles about getting patient involved in their decisions, about their care, about making sure they don't come to harm, but also about making best use of resources, too. So there's a real strong ethical framework to that. But change doesn't happen with this kind of thing unless there's a change in culture on changing culture, where treatment, escalation, planning, having those conversations becomes the normal process. And Jane and Lisa both mentioned this in their talks, and I think this is a key importance that achieving a change in culture is how you can define success in this area having a vision. I think it's really important then because it gives you something to aim towards. It gives you an intention to work towards but also gives you an anchor point to fall back on when inevitably challenges and bumps in the road arise. So anticipating some barriers now put up the most common objections, I suppose, to tip in the acute sector were just too busy. That's certainly the most common. One is very much a time pressured environment, and that's certainly the most common thing. But these other questions come up time, Time again. This isn't my job. I should be done later, and that should be done by someone who's got more experience. Or maybe I just don't believe in it. What evidence have you got for this is one of the strongest objections I have had in the past. What evidence do you have? This is going to make a difference. There's a benefit here or simply I'm just not comfortable with having these conversations. I don't like that I'm not trained in this having a conversation with a patient about their wishes or expectations or or realism, perhaps towards the end of life. So that's let's just tackle it to those in turn, mhm. So too busy, the one that comes up most regularly because I work in in any department, which is just as busy and just as overcrowded as pretty much every emergency department, not just in Scotland, of course, the UK, but indeed in Western health care, maybe around the world. So our waiting room can often look like this picture of the top, the sea of faces waiting to be seen for several hours, maybe into many, many hours in some cases. And I can feel that we're just dealing with this massive tsunami, this huge workload to get through, and that can lead us in a very difficult situation where we feel perhaps overwhelmed or under pressure just to turn through the work to get through this huge number of patients. But I believe we have a choice. We can choose just to keep our heads down and say I'm very busy and just to keep on seeing the patient, next patient, the next patient, the next patient, I'm trying to get through that workload, or we can choose to remember that each one of those fish is it's one of those persons. Each patient is an individual. An individual who has their own wishes has their own concerns, has their own identity, their own fears, and we can choose to come back to the compassion that we may be had when we started to do our medical job or nursing job or whatever it is. The compassionate perhaps, has maybe being leaked out of us in this very difficult and challenging times. So that's the choice I believe we have. I think this quote from Will Karen's, an Australian palliative care physician, sums it up really well. A week long. I to admission, can save you from having a 10 minute conversation with the patient. Yes, this is a bit tongue and cheek, but this for me emphasize, is what happens if you don't have a conversation. You do kick the can down the road or try and just put it into the long grass. Having a conversation with a patient really starts the ball rolling with some of the important decisions that need to be made and even in even in the business and even in the chaos and car dealership, an emergency department spending a little bit of time to have that conversation is really, really worthwhile. So again, one of the objections with this is Well, I don't have time it's too busy. Uh, well, my point I'm trying to make with this side is that the information that you need to make an escalation decision is information that you would have really have you done your job got already as part of taking a history. So this is about establishing the context of the presentation, each one of that tsunami or faces as an individual. And they all have a context, their presentation, my context. I mean, what's been happening in the run up to this presentation to our service? What other comorbidities Where do they live? Particularly that's a nursing home or a care home. What about their activities of daily living? It doesn't take long to look at the clinical portal or similar online database to see if there's a previous anticipatory care plan or an EKG, which is an electronic key information summary. Or indeed, if the patient has a previous DNA CPR, these things can be accessed rapidly. We can even access them before the patient arrives if they're coming in as a standby from the ambulance service. So my agreement back is that this is exactly what we'd be finding out anyway for the patient. This is not extra work. On top of what we've been doing already. I'm establishing This context is really important, not just for what the patient's going to need, but help us make an accurate an informed decision. So let's talk about not done by me. This should be done by somebody else. The positions of the care of the elderly should do this further down the road. What about that argument? Well, the first thing I'll say about that is what about this continuity of care? By that, I mean, whenever you see a patient in the emergency department and they admitted they might be seen by half a dozen different conditions in the next 24 hours, maybe the junior medic, registrar, one consultant to be seen by the junior during the night and then seen by another one the next day and then perhaps seen by further person after that. So unless you get the decision making right at the start will be so many different people picking up on that in the next 24 to 48 hours, you're getting it done right at the front door. I think it's really important what you don't want, like these two guys in the picture will be passing the buck on to the next person. What we've seen in my hospital, certainly around other departments, is that when there isn't a treatment escalation plan, you get these defaults protocol. So whenever there's an escalating new score, recognition of the deterioration of some other way that the protocols are followed. So there's a protocol for respiratory distress. There's a protocol for heart failure or whatever it is that's perceived to happen, And protocols don't really respect the patient's wishes. They don't really take into context what's been happening before. That affirmation bias is when the decision or a conclusion that's majorly, is followed on by people who follow the patient after that. So an example would be an emergency department if I made a diagnosis of heart failure. But actually the patient had pneumonia and start treating for heart failure, and that was then continued by admitting doctor and the one who sees the patient after that. The one who sees after that and nobody's actually picked up that actually need some antibiotics, for example. Similarly, with a patient who is not recognized that they would benefit more from a palliative care approach rather than an escalation of their care that continues on in the admission. But they still get escalated. They still get the next treatment, the next investigation. Whether that's the right thing to do, or perhaps not so starting the decision making early, I think has a clear benefit for the patient. What about evidence? What evidence do you have? This is the right thing to do. Well, in 2016, when I started this work, there wasn't that much. But since then there's been a whole room of evidence that that that's come to light and a number of different ways. I have picked up a few papers here, which I think, hopefully outlined some of the key benefits for patients and their families in the hospital. So the top one parent that rain in Australia was one of the kind of groundbreakers I think, a central piece of work she done, describing that patients with uh taking place are much more likely to have the end of life care preferences respected. Now my own paper that I got published in 2018 looking at Harm, and I was comparing patients who had a tip with those that didn't. And if you don't have a temp, you're doing twice as likely to have a non beneficial intervention in your last admission before you die, but also three times more likely to have a harmful intervention done to you at the end of life without a temp in place. What inhaler you will hear from shortly did this paper looking at patients who had a tape versus those who didn't in terms of the relatives who may have complained after the patient died. So if you've got a tip in place that implies that there's communication that's happened, there's been a recognition that the need for communication with the patients and their family they were twice more likely to complain if there wasn't a tip in place and usually the top produced Overall I two referrals in this paper by Fatal and the BMJ open. So I guess I could add that, anecdotally, the intensive care stuff from my own hospital report that in the last few years they get much, many less referrals from from, uh, just a day, but also from acute awards for patients for I t consideration. Because these conversations are happening earlier. I've highlighted those four papers not just because I like them, but but also for the reason that this highlights the ethical consideration that we have here respecting autonomy, first, doing no harm doing what's the benefit for the patient and also using the resources that we have that are disposable in the best way available. I know some of the questions earlier about ethical consideration. Well, here's some really good evidence that it helps address those very same ethical considerations. So what about the consequences of escalating a patient? Or perhaps escalation wouldn't be the right thing to do. Now I've picked out frailty here because this is something that there's a lot of emerging evidence for. I do. I have simplified, uh, some of the conclusions and these papers for the for the slide effect. But Palmer concluded that failed patients don't survive emergency laparotomy when this was compared to patients. Uh, similar demography who worked for real male patients don't survive. Cove in 19 concluded to it in the Lancet in 2020 and failed patients don't survive CPR. Uh, the agent aging 2021. So for me, the consistent bottom line, the consistent thing that's coming from these more recent piece of evidence is that filter is a clear and consistent predictor of survival outcome. Surely then we've got an obligation to consider frailty. When we're making a treatment escalation plan. We know that we shouldn't be subjecting patients who are frail, too. Significant escalation if it's not going to work. And I think then again, we have an ethical responsibility to do the right thing for our patients and bring that evidence to light as part of our conversation. So I'm not comfortable having these conversations. This isn't my thing again. Objection that comes up regularly. Well, for me, this is about getting over your fear of having a conversation where you're talking about the patient might die, and that just for me comes with practice. Nobody likes breaking bad news for the first time, but you do get better at it. You do get used to it, the more you do it, perhaps go along with somebody who's better, or you perceive them to be better at having these kind of conversations than you are. There's a number of communication skills course, for example, the essential communication for healthcare workers which is a sin based course, which I think is really useful. Or there's things like the red Map tool, which is a check box. Number of That's an acronym which was designed by any chest pain at the start of the pandemic. And I think it's again. It's something really useful that can you can fall back on, uh, when having a conversation that perhaps you're not that comfortable with whether that's in person with the patient, whether it's with the relatives or as what happened during the coated pandemic all the time was having these conversations on the phone, which presented its own challenges and difficulties. But again, the resources out there to help. So how do we get the success? Well, hopefully we've had our vision that we set out right at the start, and then with perseverance, we were expecting all those bumps. You know, we're expecting those objections that we can overcome them with time, so achieving a culture change isn't just a benefit for for the individual patient will be a benefit for the staff benefit for your hospital to have picked up a few of those things. But I think again are the most useful, most relevant in this situation and the last thing there knowing that you've done the right thing for your patient. Maybe you've only got one chance to get it right for that patient, but you'll know you'll have that satisfaction of knowing that you've done the right thing. Certainly, I find working, uh, with the introduction, treating the escalation plans and and seeing the benefits that happen. That has been one of the most rewarding parts of my work, certainly in the last number of years. So I just want to finish with this slide. We're seeing a dying person's remaining time is wrong, says Professor Rob George, a palliative care consultant that Christopher's Hospice in London. That's a sentiment I wholeheartedly agree with, and I very much hope you do, too. So I know there might be some questions, but I just want to leave you with some suggested further reading or indeed, listening on the subject. Uh, there's the questions, and I'll take them. But I guess that will be a opportunity to discuss this further in the plenary at the end as well. So thank you very much for attention. Thank you for listening. Thank you, Calvin? Um, really good to hear about the ethical. Um um, struggles we have sometimes with having these conversations and the difficulty having these conversations, um, being mortal. And the way we die now are definitely two books I would always recommend people to read. Um, I think they are both excellent. And, of course, Robbins coping with crisis book. That's there as well. I should probably say that, um, there are There's a question coming in from Robin, but it hasn't quite filled it in there. I suppose. Just while questions kick off, I was going to ask you, I I think steps are a surrogate for, um, you know, a communication. It shows that that communication's been had. Um uh, it's maybe a nudge towards having that conversation both with the patient, but also, I like what you're saying that it it sets that example for the hospital. Um um, you are completing them in the emergency department. What? What What are the thoughts about physicians? Um, downstream, Um, when they see a patient coming through with a tip from the emergency department Well, I think, as it may be related to, I think you're setting the benchmark for the for the care of that patient. By making the tap in the emergency department, you're selling out the conversations that have happened, your setting out the consideration of what the patient wants as well. I think whenever you can come back to that and you can share that and you can show the benefits then as well I get The feedback I get from colleagues further down the line is they're really glad whenever the conversation has already happened, uh, in the emergency department, make their life easier. And obviously it's better in terms of outcome for the patient to Robin has, um, um asked if you could tell us a little bit more about how you convinced your colleagues because sometimes, um, any of us that are involved in improvement activities know that there are the the people at the start and the Eligard at the end and and what did you do to get everybody on board? But it does take time. I think there's no getting away from that. Whenever people see change, inevitably, they'll be resistant to change from some quarters. I think what you need to do is set the example you need to show that you can do it. You show that it's working, but also the culture comes from the bottom up as well as the top down you get sort of. I told the juniors how to do this with the registrars that the nurse is on board. So that's all part of changing culture. Whatever you can show and demonstrate the benefits, whether that's through teaching or things like Eminem reviews. Whenever you can demonstrate the clear benefits here, people do pick it up with time. It will be people that are early adopters like you mentioned, and people pick it up late after a while. Once you can show that there's a culture change, it's really hard to resist that you need to go along with it, particularly when you put a junior doctor coming along to, say, a resistant consultant with the tip for nicely completed. And they're looking for that consultant signature. That's when I think it's a real win for the patient, to the department for the hospital. There is a question from Helen, um, Tyler, Um, that although we think that having the conversation might be the right thing to do, you know people worry about getting the conversation wrong, Um, and whether it harms the patients or harms the doctor patient relationship, which is difficult to come back from? Yeah, I guess that's another objection. I've heard along the line that you could be removing hope in some way, but that's certainly not my experience. I think when you're taking your frame it along the lines of talking about, what's your understanding of what's happening just now, what's important to you? What fears do you have whenever you start off the conversation with those kind of questions? I think you very much see that the patient them, as previous speakers have mentioned, Welcome that you take it on board and they're glad that they're almost there unburdening that this, that this situation that maybe I've had this a few times. You're the first person that's talk to me honestly about this. Uh, actually, as I said, it's a really rewarding experience, So certainly you're not removing hope. Quite the opposite. You're giving hope, perhaps of dignity. Hope that your wishes will be respected and try to maybe remove some of the fear is that patients have, which you only know about. If you take the time to speak to them? Um uh, William Anderson has asked a question about, um, In many ways, it's a It's an improvement intervention. Did you gather any indices? Any data around improvement to help Proceed your colleagues? Or are you just a very persuasive person? Well, maybe a little bit of bladder, but I think that things have changed. Our the tap is not part of a consideration on the Eminem Review form, Uh, and we can demonstrate that consistently, whenever attack was present that the patient's wishes are more likely to be respected, and they don't have their care escalated unnecessarily. But conversely, when there's patients that we review and there's been no discussion, they're the ones that are much more likely to have had things done to them that didn't make any difference or indeed were harmful. I think it also emphasizes, um, whenever you have communication, you're more much more likely to have the patient's family on board with that as well. Um, I guess things are looking forward. Um, audit work's important reviews of what's happening would be further down stream to see what the uptake still there and again, that's something that I'm involved with in the wider hospital. Um, so I hope that answers the question, but maybe there will be some more points to come up from that. Robbins planning to cover a little bit about, uh, Paula was asked a question about patients, um, and staph from different cultural backgrounds, um, influence and the difficulties of having the conversation, Any experience of that? Yeah, absolutely. And I think we just need to be aware of the sensitivity around that. But as I said, I think when you open the conversation with what's your understanding, Uh, I think it's a question you don't ask often enough. Uh, and this is coming straight from the glands, but you need to frame the conversation around that, uh, and then focusing on what's important to you. What matters to you. I mean, these are questions that you seem obvious with hindsight, but it can be so useful and again taking the mathematics is like that. That you're sick enough to die is a really useful thing to introduce into a conversation, using the word sick enough to die. Uh, that's really helped me enormously. I think that I'm being honest in the last few years. It's just something that just registers clearly, uh, that that death is one of the things that could be happening here. Previously, whenever you had said to the patient, should I contact the priest? That might have had the same effect, but I think that kind of that that's more subtlety. Uh, the fact that you're emphasizing things like dignity, you're respecting wishes. These things will help get the patient onboard, irrespective of their of their cultural background. Whenever you emphasize that you're still going to be doing everything that's going to make them comfortable and preserve their dignity, making sure they're getting the care that they need and I think these things will contribute, uh, are enormously helpful. Regard is irrespective of the patients background. It may be surprising how much we think that patients know about what's happening compared to what is actually the reality, and and you think they have the chance to discuss things and and let us know things. But they may not. They may not realize how sick they are. Absolutely. Um, Fiona, if I can ask you just another couple of questions because we got a little bit of time is Fiona paraphrase. Our question is when you know the clinical condition changes and it's more of an improvement rather than a deterioration and the ability to, um, change that treatment, escalation plan Any worries from your part that you've seen them in the e. D at their worst, and that goes with them and it doesn't get changed, And, um, and that may be a danger to the patient. Maybe I can understand that anxiety, I think Jane, maybe address that a bit in her talk when she mentioned about the condition changes that should be a prompt for the hep to be reviewed. I think there's a much, much greater likelihood of the patient deteriorating and then coming to harm to escalation. If I'm honest, Certainly that would be the conclusion from the research that I've done and read about as well. But certainly in the perhaps rare situation where patient improves dramatically, this conversation still useful. If you've established and they're understanding you've established what's important to them, what their fears and anxieties are, things that might be willing to trade off that's still really useful. That's really useful information, even if the decision or the the thoughts about what the goal of care is. Changes that information is still really helpful, and we'll continue to be even after that admission. Great. There are other comments further up saying that they really enjoyed the presentation and it was an outstanding presentation. So thank you very much and you'll join us at the end. Um, for the panel discussion and a few more questions.