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1103390 RCP Journal of the Royal College of Physicians of EdinburghRobin Taylor et al. Clinical Journal of the Royal College of Physicians of Edinburgh Responding to the deteriorating 1 –8 © The Author(s) 2022 patient: The rationale for treatment Article reuse guidelines: https:/.o / .117 /17152rm03390ns escalation plans journals.sagepub.com/home/rcp 1 2 3 D Robin Taylor , Calvin J Lightbody , Richard Venn and Alastair J Ireland 4 Abstract A Treatment Escalation Plan (TEP) is a communication tool designed to ▯improve quality of care in hospital, particularly if patients deteriorate. The aims are to reduce variation caused by discontinuity of care; avoid harms caused by inappropriate treatment and promote patients’ priorities and preferences. The TEP is based on the goals of treatment – ‘What are we trying to achieve?’ The goals take account of the context of acute▯ illness, the consequences of interventions and discussion with the patient. They should reflect a shift away from ‘fix-it’ medicine to what is realistic and pragmatic. A TEP has three escalation categories: full escalation, selected appropria▯te treatments and palliative/supportive care. Other appropriate/inappropriate treatments are also recorded. Treatment Escala▯tion Plans are associated with significant reductions in intensive care unit (ICU) admissions, non-beneficial int▯erventions, harms and complaints. Treatment Escalation Plans contribute to staff well-being by reducing uncertainty.▯ Successful implementation requires training and education in medical decision-making and communication skills. Keywords deteriorating patient, treatment escalation, clinical decision-making, moral distress Introduction other, often unwritten limitations to treatment. There was a clear need for a fit-for-purpose tool. 4 Patient safety is a major consideration in the delivery of high-quality care in hospitals. Strategies to ensure patient In this review, we outline why TEPs have the potential to fulfil that role by reducing unnecessary variation in practice, safety are designed to identify, prevent or if possible elimi- avoiding harms and waste, and promoting a personalised nate clinical harms. The risks may be related not only to processes and procedures but also to clinical decisions and approach to care based on patients’values and perspectives. These are important dimensions of Realistic Medicine. We their consequences. Risk–benefit analysis is essential to will describe the key components of a TEP, how and why good decision-making. The Structured Response to the Deteriorating Patients is TEPs should be implemented and the outcome-related evi- dence to support their use. designed to reduce risks in acutely ill patients. The aim is to identify deterioration early and intervene promptly. Early warning scoring (EWS) is a key element in fulfilling this Treatment Escalation Plans – why? 1,2 objective. But when EWS criteria for responding to dete- Among other things, Morbidity and Mortality reviews rioration are met, what happens then? Too often on-call staff deliver treatments that are narrowly focused on the identify factors that may have contributed to poor quality pathophysiological process that has led to deterioration, for example, heart failure or sepsis. Urgent interventions may have undesired consequences or result in unintended harms. 1Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK 2University Hospital Hairmyres, NHS Lanarkshire, East Kilbride, UK Even worse, they may be contrary to the patient’s wishes. 3University Hospital, West Sussex, UK One of the aims of a Treatment Escalation Plan (TEP) is to 4Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK avoid these problems. Corresponding author: Treatment Escalation Plans were first described by Fritz D Robin Taylor, Department of Respiratory Medicine, Royal Infirmary et al. Historically, the original TEP was the Do Not of Edinburgh, NHS Lothian, 51 Little France Crescent, Edinburgh EH16 Attempt Cardiorespiratory Resuscitation (DNACPR) order. 4SA, UK. Unfortunately, over time DNACPR became a proxy for Email: rtaylorscot@gmail.com2 Journal of the Royal College of Physicians of Edinburgh 0(0) Table 1. Organisational and clinical problems that may be mitigated using a TEP. Problem Comment Discontinuity of care leads to poor On-call staff, including Rapid Response Teams, are often unfamiliar with▯ the decision-making patient. Access to key information about a patient’s illness, goals o▯f treatment and treatment preferences is beneficial.1These are less likely to be ignored or reversed if relevant information is effectively communicated. One-size-fits-all interventions are often In the absence of a TEP, indiscriminate or protocol-driven interventions may give indiscriminate rise to harms more than benefits. A personalised response is associated with a 3,11 reduction in medical harms. Patients’ perspectives and preferences may Even in emergencies, a patient’s values and priorities should be take▯n into account. be neglected The creation of a TEP prompts discussion with patient/family. The TEP process provides an ethical Honest communication, respect for patient autonomy and the obligation to avoid framework for acute care harms (primum non nocere) are ethical responsibilities. DNACPR discussions in isolation may be Discussions about DNACPR without reference to the patient’s illness a▯nd harmful prognosis are associated with misunderstanding and complaints. This problem can 12 be avoided using the TEP. Inexperience and uncertainty lead to When out-of-hours staff are without guidance or support, they may experience decision-making insecurity and moral distress dissonance between what they perceive to be the right thing to do and what they feel they are expected to do. When dealing with an emergency, they often feel obliged to ‘do something’ even if that is inappropriate or potenti▯ally harmful. care and possibly to a patient’s death. The factors may be Asummary of issues that are addressed by the TEP pro- multiple and/or sequential, and include decision-making cess is outlined in Table 1. mistakes or neglect by individuals, or the adverse effects of interventions, or importantly, systems errors. They are Treatment Escalation Plans – who? often avoidable. The TEP process addresses some of these issues at least In an ideal world, every patient admitted with acute illness in part. The central goal is to ensure that treatment given to would have a TEP. Even in patients for whom the response to unstable or deteriorating patients is not just timely but deterioration is ‘for full escalation’, having that information is▯ 6 appropriate. Too often the plan for a patient’s care beyond very helpful to on-call staff.Clarity provides security for clini- what is immediate has not been considered or formulated. cal decision-making by staff who are unfamiliar with the patient. If the patient then deteriorates and relevant information is In practice, a TEP should be put in place for selected lacking, the presumption by on-call staff is that treatment patients: should be curative in intent. Alternatively, even if consid- ered, the specific details of a plan may not be easily • Clinically unstable, or at risk of deterioration, or accessible. ‘sick enough to die’. The TEPpro forma is a communication tool. It provides • Moderate-to-severe frailty, or admitted from a nurs- readily accessible guidance concerning a patient’s current ing home. treatment (now), or for when the patient deteriorates either • Progressive organ failure with/without expectedly or unexpectedly (later). In the absence of a TEP, co-morbidities. interventions may be indiscriminate. Discontinuity of care, • Progressive incurable disease, for example, demen- insecurity in urgent decision-making and risk-averse tia or motor neurone disease. behaviours influence decisions made by out-of-hours staff. • Adiagnosis of cancer, especially if it is advanced or Over-treatment with non-beneficial interventions, espe- is being treated currently. cially if a patient is on an end-of-life trajectory, is com- • At the request of patient/welfare attorney or guard- 7,8 mon. This often goes hand in hand with under-treatment ian/nearest relative. with palliative treatments – these may in fact be a priority • To continue provisions of an existing advance care in addressing a patient’s needs. plan (ACP) or similar. In addition, when a lead clinician or a multidisciplinary team decide on the goals of treatment for a patient, consist- In hospital localities where the risk of deterioration is ency is important. It can compromise quality of care, as relatively high, TEPs may be mandated for every patient: well as create tension and frustration, if out-of-hours man- for example, among patients admitted with fractured neck agement is not in keeping with earlier clinical decisions. of femur or those admitted to high dependency units or Before instituting TEPs in his department, a surgeon com- patients being stepped down from intensive care unit (ICU). plained: ‘I used to dread coming in on Monday morning to The decision in favour of this practice is made by team find that a decision favouring conservative management for consensus. a sick, frail patient had been ignored over the weekend, and The TEP is not legally binding and is not set in stone. Regular in response to deterioration the patient had been taken to review is important and where there is a structured ward round theatre’. template, it should include a prompt for TEP review.Robin Taylor et al. 3 Treatment Escalation Plans: What? just about new processes and documentation, but a culture change in medical decision-making. TEP design Over the last 70 years, the approach to acute illness has Designing a TEP template is often the focus of disagree- almost always been characterised by what might be termed ment , but the outcomes are remarkably similar! The TEP ‘fix it’medicine. In this paradigm, the patient’s clinical ill- has to capture information about a complex set of issues: the ness is defined in terms of a pathophysiological process, for patient’s decision-making capacity; the understanding of example, bowel obstruction. Thereafter treatment is patients or family members about their illness; agreement directed towards reversing or mitigating the pathological about the goals of treatment; escalation/limitation regarding process. location of care and escalation/limitation regarding specific It is difficult to argue against the ‘fix it’approach. It is interventions. Many validated TEPs are now available. 14–16 logical, pragmatic and attractively focussed in its scope. However, in the age of multiple comorbidities 18 that model Reinventing the wheel is rarely worth the17ffort although in some settings modifications are helpful. is often inadequate. Nearly 30% of patients admitted to The recorded details in a TEP include: hospital acutely are in the last year of life9 with their tra- jectory related to relapsing malignancy, progressive organ 1. Patient capacity to give consent to treatment. failure or severe frailty. These features make it less likely 20,21 2. Patient/family perspectives and understanding that even optimum treatment will fix things. Rigid based on discussion with the clinician. adherence to the ‘fix it’approach also means that palliative 3. Goals of treatment, based on the context of the ill- treatments are introduced far too late. ness, the potential consequences of medical inter - Shared (or supported) decision-making is the basis for patient respect. It is arguably at its most difficult when a ventions and agreement with the patient (see later section). person is acutely ill. The background often includes pro- 4. The ceiling of treatment now, or the strategy for gressively deteriorating health and the current situation escalation later in the event of further deterioration. may be potentially life-threatening. Yet urgency often Broadly, there are three levels of escalation: drives interventions that disregard the context of the illness, the patient’s priorities, whether or not it is desirable to • Full escalation reverse what seems to be reversible, or the likely conse- • Selected/appropriate treatments (including palliative quences of major interventions including futility or harms treatments) (N.B. in relation to frailty0,2). These complex issues need to be processed and discussed in an honest manner. Yet • Comfort and supportive care (including palliative treatments). acknowledging reality is something that clinicians seem reluctant to do.22 It is stressed that palliative treatments should not be It is difficult to convince doctors that avoiding harms is important: ‘primum non nocere’. Rather, they cite uncer - reserved for the terminally ill. For categories (2) and (3), details about investigations, procedures and treatments that tainty as the reason for over-treatment. The moral high are considered appropriate/inappropriate, including pallia- ground is claimed by those who ‘give the patient the benefit tive treaments, now or later, are recorded. of the doubt’, who practise ‘last chance medicine’, or who were ‘only doing their best’. But what is best when treat- 5. The DNACPR status. ing a pathophysiological process is not necessarily best for the patient. The test-of-change model for assessing the performance of The introduction of the TEP process often challenges a TEP can be complex. 3,12–1What to measure? Is the focus these attitudes, but the outcomes are positive. 24 Many downstream problems can be avoided if decision-making is on process or on outcomes? Process involves addressing questions such as ‘Is the pro forma understandable and easy mutually agreed with the patient, or is shared with col- to complete?’‘Is the TEP being used when it should?’ leagues in a team whose culture tempers zealous over- ‘What are the obstacles to its use?’On the other hand, out- intervention. The team culture is hugely important in the comes are related to the quality of care received. adoption of TEPs. Examples of TEPs are also provided in Supplemental Asimilar culture change is needed in the realm of public Appendix 1 (paper version, NHS Greater Glasgow and expectations. This is more difficult. Hospitals are where Clyde) or on line at https://vimeo.com/610516412/ things get fixed. The advent of numerous life-saving medical c2bdb6585a (digital version, NHS Lothian). technologies and treatments, together with increasing emphasis on patient autonomy, mean that appropriate limita- tion to medical interventions is hard to accept. Societal per Treatment Escalation Plans: How? spectives on death and dying reinforce these elements. We are a death-denying, death-defying culture. ‘Do everything Training and education: The medical you can, doctor’is the imperative. In the media, ‘the battle decision-making culture against cancer’or any other life-threatening illness, elevates The implementation of TEPs across acute medical and sur- healthcare to the level of a war that must be won. Those who gical areas is a significant undertaking.At its core it is not win are heroes. What does that say about those who die?4 Journal of the Royal College of Physicians of Edinburgh 0(0) Table 2. The benefits of time spent creating a TEP at the time of admission to hospital, based on agreed goals of treatment. The patient • Non-beneficial treatments and harms are more likely to be avoided. • To protect the patient from medical harm fulfils an ethical responsibili▯ty. • Once started, it is difficult to stop the conveyor belt of interventions▯ in hospital. The TEP facilitates treatment limitation before inappropriate treatments get u▯ r way. Medical/nursing staff • Where major interventions, for example, surgical operation, are agreed in advance to be inappropriate, the response to deterioration is less likely to waste sta▯ff time and effort. • Decision-making security: moral distress due to uncertainty or inexperie▯ ce is less likely to occur. Hospital services • Patients with TEPs are less likely to be transferred to the intensive ca▯re unit (ICU); less likely to complain about treatment or about DNACPR; and costs associated with hospital stay are likely to be reduced (See Table 4). The attending clinician • Personal satisfaction about doing the right thing. Appreciation by patie▯nts and family members that they have been listened to and their views respected. Being willing to set aside the pre-eminence of ‘fix it enough time for the TEP process, especially at the front medicine’is often problematic in the minds of patients and door. Addressing the immediate medical problems is their family members as well as clinicians, no matter what the priority. illness trajectory or prognosis. We have all had to deal with Some responses to the complaint ‘I don’t have enough family members whose insist on ‘last chance medicine’for time’are set out in Table 2. When time is at a premium, a their relatives. It seems easier to capitulate. Yet to limit selective approach is relevant. Which patients are likely to rather than escalate at an appropriate time is not just realis- be at increased risk of harm in the absence of a TEP (see tic, it may spare the patient from unnecessary ‘iatrogenic Table 1)? The TEP process is not as time-consuming as is 25 suffering’. Early palliative treatment is beneficial but too alleged. In most cases, the work has already been done often is a last resort despite evidence that, faced with life- (assessing prognosis, discussing treatment options and limiting illness, patients often opt for quality of life not obtaining agreement). Completing the pro forma does add quantity.26 to the task, but it is time well spent. Furthermore, not eve- It is in this context that the TEP ‘process’i27beneficial. It rything needs to be addressed in the first pass. The TEP is not just patients but families who benefit : the risk of process can be incremental and some elements can be moral distress among hospital staff is also mitigated. addressed later. Other factors that contribute to the reluctant mindset need to be recognised and addressed empathetically. Firstly, Training and education: Communication skills there is immediacy, reinforced by anxiety-driven complic- ity on the part of patients – ‘You decide, doctor’. Immediacy As well as reforming the medical decision-making culture, militates in favour of short-term goals and against conside- TEP implementation requires communication skills exper- ing what might be needed later if things deteriorate. In an tise among health professionals. Psychological barriers and environment where responsibility for a patient’s care is cognitive biases need to be addressed. Many clinicians often passed to the next team within hours, there are limited avoid discussing issues such as prognosis and the potential incentives to spending time considering the consequences for adverse consequences of treatment. They may state that of intervention, or the possibility that treatment may need their communication skills are poor, and they are not good escalation. ‘We will deal with that if and when it happens’. at ‘bad news’as if this is an irreparable trait. They exhibit But is that a responsible approach? avoidance behaviour. 28 Secondly, there is our historic approach to consent. It It takes time to convince colleagues that discussing and seems extraordinary that written informed consent is man- choosing what is feasible and realistic is not a luxury but a datory prior to interventions, such as endoscopy, but not for duty of care. Improving communication skills requires admission to the ICU for non-invasive ventilation or ino- long-term concerted effort with varied approaches. We tropes. We are not proposing the expansion of written con- have used multidisciplinary team meetings, grand rounds, sent requirements: but ‘no decision about me should be simulation training, videos, Intranet-based learning mod- without me’points the way to appropriate ethics in medical ules and one-to-one coaching sessions. decision-making. Each of these methodologies has their place, but no mat- Finally, the platform for determining the appropriate- ter the technique, the TEP process has to be owned by insti- ness of care – or its escalation – is the answer to the ques- tutional leaders and individual consultants. Trainee doctors tion ‘What are we trying to achieve?’ Short term-ism only adopt the TEP process in a pro-active permission-giv- provides only a very skewed answer. Undoubtedly, decid- ing environment. ing on the overall goals of treatment is a time-requiring pro- cess, but it is one that we all need to accept as essential to good quality care. Time and other factors The key components that underpin the goals of treat- Many clinicians agree that TEPs are a good thing, but the ment are outlined in Table 3. The call to clinicians is both obstacle they raise most frequently is that they do not have ethical and altruistic. Understanding that decision-makingRobin Taylor et al. 5 Table 3. The components of medical decision-making towards determining the ‘goals of treatment’. Component Description Examples Context The context of the patient’s presentation will help to Aspiration pneumonia. Patient #1 is 45, gets very determine whether treatments are feasible, achievable drunk and vomits. Patient #2 is 85, has Parkinson’s or appropriate. Consider: comorbidities, the illness disease, advanced lung disease, cor pulmonale and trajectory and prognosis, performance status and infected leg ulcers. Her Clinical Frailty Score is 7. She current levels of frailty and responses to treatment in lives at home with three carer visits per day. These previous episode. two cases may be very similar pathologically, but the goals of treatment are likely to be quite different. Reversibility Is the current presentation due to a process that is Hypercalcaemia with acute kidney injury. Patient #1 is reversible? taking multiple medications, and mistakes her vitamin Depending on the context, aiming to reverse a D tablets for her diuretic. pathophysiological process may or may not be the Patient #2 has stage 4 squamous carcinoma of the right thing to do. lung with bone metastases. Consequences The adverse effects or long-term consequences #1: Clinical Frailty Score is a significant factor of major interventions may influence the determining outcomes for many interventions patient’s wish to accept the risks associated with including laparotomy 20and chemotherapy. #2: treatment and give consent. Long-term cognitive impairment resulting in loss of independen31 is a common consequence of ICU admission. Discussion Discussing the diagnosis, the likely prognosis (‘What Outlining the best- and worst-case scenarios can does the future hold?’), the risks/benefits and mitigate the problem of uncertainty when achieving consequences of treatment, and inviting the patient/ agreement on goals of treatment and decide on family to offer their perspective (‘What are your appropriate levels for future escalation. thoughts?’) leads to shared decision-making. early in the patient’s admission will likely shape their sub- specific evidence that describes patients’perspectives on sequent care – the ‘conveyor belt effect’, it is an ethical TEPs. However, the TEP process facilitates shared deci- 34 responsibility to do everything possible to optimise that sion-making for which there is a substantial literature. care beyond the present moment. It is also a collegial Further research into overcoming the barriers to TEP use responsibility to ‘make it easier to do the right thing’and and into clinically relevant outcomes is still needed. avoid the difficulties that on-call staff so often experience when guidance is not available. 29 TEPs and ACPs: Is there a difference? Advance (anticipatory) care plans have developed widely TEPs outcomes: The evidence since their introduction in the USA, 40Australia 27 and in There is growing body of evidence regarding clinical out- other Western countries. 41,42 comes associated with TEPs. Deciding on the best outcome The ACP is a summary of a wide range of healthcare measure is not easy because the TEP is a complex interven- objectives that have been discussed and agreed with the tion designed to enhance quality of care from a number of patient. ACPs are informed by a patient’s present health angles.Also, given that a key aim of the TEP is often to set conditions but also anticipated future trends. limits on interventions that are potentially harmful or con- A key aim of an ACP is to engage with patients and trary to the patient’s wishes, it is methodologically chal- empower them to articulate their priorities regarding future care at a time when they have decision-making capacity lenging to assess the benefits of something that is not to be done! This requires controlled studies. However, most and there is no immediate crisis. These aims are at the heart reported studies are retrospective and inadequately pow- of Recommended Summary Plan for Emergency Treatment ered, or they report outcomes that rely on subjective assess- (ReSPECT) that is currently being developed by the UK 43,44 ment. Only rarely have TEPs been tested in a randomised Resuscitation Council. trial,7and only two studies can be compared to one another. At the time of a hospital admission, while any ACP Both of these concur that TEPs are associated with a reduc- needs to be taken into account in the construction of a TEP, 3,11 tion in harms. there are pragmatic limits to a pre-existing ACP’s useful- Overall, the weight of evidence confirms that TEPs ness. By definition the patient’s health status is now in flux. result in improved quality of care (see Table 4). Treatment The severity and prognosis of the current illness need to be re-evaluated, including the possibility that the acute event Escalation Plans reduce inappropriate out-of-hours treat- ment, referrals to the ICU, patient harms at end-of-life might be life-threatening or even terminal. The immediate including delayed palliative treatments, inappropriate anti- goals of treatment and escalation options need to be biotic usage, hospital costs, relatives’ complaints about updated. Specific hospital-based interventions need to be quality of care and DNACPR orders, and anxiety and weighed as to their appropriateness. Furthermore, the depression among bereaved family members. There is no patient’s current perspectives on treatment priorities need6 Journal of the Royal College of Physicians of Edinburgh 0(0) Table 4. Summary of studies that have reported outcomes in relation to use of TEPs. The articles cited were obtained using the search terms ‘treatment escalation’, ‘ACP’, ‘DNACPR’ and ‘deteriorating patient’. Outcome measure References Results 3 Reduction in medical harms Fritz et al. Harms occurred in 23/71 patients with DNACPR only vs contributing to a patient’s death 4/44 using Universal Form of Treatment Options (UFTO) (TEP equivalent) (p=0.006). Harms per 1,000 patient days 34.7 vs 21.8 (p = 0.01) Reduction in medical harms in hospital Lightbody et al.1 For every harm among the 155 patients with a TEP+DNACPR, there were 2.77 (95% CI=1.96–3.92; p<0.001) in the group with DNACPR only. Reduction in inappropriate treatments Stockdale et al.5 11% of patients with TEP received inappropriate care compared to 44% without a TEP (no statistical analysis). Reduction in non-beneficial treatments Lightbody et al.1 For every non-beneficial intervention among 155 patients with a TEP+DNACPR, there were 1.99 (95% CI: 1.48– 2.64; p<0.001) in the group with DNACPR only. Reduction in inappropriate antibiotic Wilder-Smith et al.36 2/28 patients (7.1%) with a TEP that included an use at end-of-life antimicrobial ‘ceiling’ received antimicrobials at time of death, compared to 18/53 (34.0%) among those who did 37 not have a ‘ceiling’ (p< 0.005). Reduced hospital costs associated with Bouttell et al. Patients with a TEP (n=152) had a mean reduction in non-beneficial interventions hospital admission costs of GB £220.29 compared to those without a TEP (n = 132) (p 0.001). Reduced number of referrals to intensive Fadel et al.4 The introduction of a TEP across regional hospitals care unit 38 resulted in a 12% reduction in ICU referrals Reduced likelihood of complaints by Taylor et al. TEPs were used signficantly less frequently in complaint relatives following a hospital death cases compared to matched controls (23.8% vs 47.2%, p = 0.01). Reduced number of complaints Shermon et al. 12 After 2years of regular use of TEP, the number of related to DNACPR orders complaints about DNACPR was reduced to zero in NHS 39 Weston Area Health Patient satisfaction with discussion Obolensky et al. 34% of patients (n=55) experienced some anxiety when about goals of treatment/TEP the TEP was being discussed, but 96% of the same patient thought that the TEP process was a worthwhile exercise to be revisited. When faced with the possibility of dying, a essential that conversations about critical illness should person’s preferences may change significantly from when focus on what is relevant to the immediate illness. 6 The they completed theirACP (this is a recurring theme reported TEP process puts things other than DNACPR at centre by clinicians in emergency departments). stage unless cardiorespiratory arrest is a genuine possibil- Our experience is that one size does not fit all. In any ity: ‘no DNACPR without a TEP’. large organisation, standardisation is legitimate only if it facilitates and enhances effectiveness.AlthoughACPs and TEPs have overlapping purposes, they are different instru- Summary and conclusions ments (see Table 5). Treatment Escalation Plans are designed to serve the needs of acutely ill patients in hospital particularly if they have the potential to deteriorate further or are on an end-of-life TEPs and DNACPR trajectory. Patients with severe frailty or advanced condi- There is wide agreement that DNACPR orders have major tions are more vulnerable to medical harms than at any drawbacks. They have been used inappropriately in the other time. Current evidence indicates that TEPs reduce past as a surrogate for other things, for example, ‘not for treatment overuse and harms effectively. transfer to hospital’or ‘not for ICU’. This has led to public In the acute care setting patients and families experience misunderstanding and suspicion as to the real intentions of significant psychological as well as physical suffering. The a DNACPR order. There is also public ignorance as to the TEP process seeks to engage with them such that they are likely success of CPR. 45More recently, in relation to the included in meaningful, supported medical decision-mak- COVID pandemic, there has been significant misuse of ing. ATEP is based on establishing appropriate goals of DNACPR, including orders being put in place without the treatment that are underpinned by patient choice as well as patient’s knowledge or consent. 46 harms avoidance. These are two important ethical require- Our own experience is that isolated discussion of CPR ments of good quality care. unnerves many patients. They may be alarmed or confused Providing TEPs is integral to the Structured Response to if cardiac or respiratory arrest is given prominence in any the Deteriorating patient. Quality improvement based on discussion, even if cardiorespiratory arrest is highly EWS or similar should be complemented by incorporating unlikely or a natural death is anticipated. It is therefore TEPs routinely into hospital practice. The TEP is used toRobin Taylor et al. 7 Table 5. Comparisons between advance (anticipatory) care plans and TEPs. Item Treatment Escalation Plan Advance (anticipatory) care plan Overlapping aims The general aims of both ACPs and TEPs are similar, namely to empower pa▯tients to discuss and express priorities and preferences about their future care. Differing time frames and Hours or days following an acute admission to Weeks or months. circumstances for use hospital. Created when patient is clinically stable,in Created as integral part of Response to the the outpatient clinic or primary care setting. Deteriorating Patient. Aims are much wider than TEP, for example, Takes any existing ACP provisions into account preferred place of death, power of attorney but these provisions need to be revised and arrangements. a updated. General vs specific treatments TEPs provide details about specific measures ACPs address the patient’s wishes about and interventions that may or may not be appropriate if a patient admission to hospital in the event of a new deteriorates during hospital admission. illness/deterioration while at home or rest home. This is relevant in relation to preferred place of death. DNACPR ACPs and TEPs both deal with DNACPR. Medical and nursing staff The TEP addresses the problem of discontinuity The ACP similarly helps to direct unfamiliar wellbeing of care. It provides guidance to on-call staff care home or primary care staff regarding the so that they are able to make appropriate patient’s priorities for treatment where the decisions based on up-to-date goals of treatment. illness trajectory is that of progressive decline. Anecdotally, moral distress among staff is mitigated by the availability of a TEP. a This point is illustrated by the similar concept of a birthing plan. A p▯regnant mother-to-be may draw up a birthing plan in anticipation for whe▯n she arrives at hospital in labour. The plan will outline her aspirations▯ for what she would like to happen once in hospital. However, in the eve▯nt of severe pain or unforeseen obstetric complications, the plan may need ▯to be revised in favour of decisions that reflect and address the curren▯t reality. Unfolding events modify the patient’s needs and treatment pr▯iorities. rationalise how a complex array of investigations and treat- Supplemental material ments is used, that is, appropriately rather than indiscrimi- Supplemental material for this article is available online. nately. The TEP is a communication tool geared towards mitigating the discontinuity of care that often characterises hospital systems. This issue affects staff wellbeing. References 1. The Royal College of Physicians. The National Early The principal barriers to implementation are: clinicians’ Warning Score (NEWS) thresholds and triggers, https:// commitment to ‘fix it’medicine; the lack of awareness that harms avoidance is important in clinical decision-making www.rcplondon.ac.uk/projects/outputs/national-early-warn- ing-score-news-2. (2017, accessed 27April 27 2020). and the perception that they do not have enough time to 2. Alam N, Hobbelink EL, van TienhovenAJ et al. The impact devote to the TEP process. 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