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TREATMENT ESCALATION PLANS – FREQUENTLY ASKED QUESTIONS QUESTION 1 Should Treatment Escalation Plans (TEPs) be used for every patient or for selected groups? In some hospitals eg Princess Alexander, Essex, TEP compliance was immediately enhanced by making it mandatory for every patient to have one. So ideally, TEPS should be used for every acute medical and surgical admission. In the vast majority, full escalation will be the intention should the patient deteriorate, and this makes completing a TEP straightforward. If targeted groups are the focus of TEP creation eg frail patients with hip fracture, then one is dependent on the person admitting the patient deciding whether to complete a TEP. The question “who should have a TEP?” is bypassed if everyone has one. The question then becomes “what should the provisions of the TEP be?” This is a better question. QUESTION 2 What is the relationship between TEPs and ReSPECT? There is a growing consensus in Scotland that the use of ReSPECT and TEPs ought to be complementary. TEPs are designed to address the immediate needs of acutely ill patients admitted to hospital. The focus is on specific treatments and interventions that may or may not be appropriate, and especially on what to do if the patient deteriorates. TEPs are based on the immediate goals of treatment for a hospital admission, and shaped by the patient’s priorities and preferences at the time of admission. Currently the development of the National Digital Programme is using ReSPECT as a prototype. In the future, a national TEP will be developed, and the aim would be to have “cross talk” between TEPs and ReSPECT via the Digital Platform. In summary, the future is not one or the other, but both: TEPs are for hospitals and ReSPECT is for Out-Patient and Primary Care settings. QUESTION 3 How is the culture of TEPs among Consultants going to be improved? TEPs require to be endorsed by Consultants, and their active participation and encouragement is essential for the success of TEPs as part of the Deteriorating Patient Programme in each medical and surgical unit. Implementation programmes need tailored education that focuses on Consultants. 1Incorporating TEPs into morbidity and mortality reviews also reinforces the value of TEPs to all members of the team, including Consultants. Another way forward is to include TEPs as an integral part of Structured Ward Rounds. A key point to emphasise: consultants are not only responsible for their patients, but also for the wellbeing of their trainee staff. It is clear that on-call medical and nursing staff feel vulnerable when dealing with out-of-hours emergencies if information and guidance is lacking. This vulnerability is addressed when a Treatment Escalation Plan is in place with consultant leadership. QUESTION 4 Are there any other mechanisms by which a culture change can be facilitated? The acceptance and use of TEPs requires bottom up and top down approaches. Support from senior management and clinical directors is essential in cultivating an expectation not just about the use of TEPs, but also shared decision making, realistic medicine principles, and values based medicine. The benefits to the organisation – notably reduced harms and complaints – should be made known by Health Board leaders. QUESTION 5 How do you decide on what is included in a TEP? There are three key elements that contribute to establishing the goals of treatment: • the context of the patient’s illness • the consequences of intervention • the conversation with the patient or their family. When a patient deteriorates out of hours and the situation is urgent, it is difficult to address each of these issues – hence the importance of thinking ahead and creating a Plan. The REDMAP tool is helpful in guiding short, focussed conversations that address the three C’s. QUESTION 6 What happens when the patient does not have decision-making capacity and family members are not present? It is an ethical responsibility of every clinician to avoid harms, and the creation of a TEP is a mechanism for ensuring harms avoidance. Harms occur in the absence of a TEP. Being unable to have a discussion with patient / family is not a reason to withhold a TEP. Obviously discussion with the patient or the family is important, and if it is not immediately possible, then every effort should be made to have the conversation with family members as soon as possible thereafter. 2QUESTION 7 Who should be involved in creating a TEP? All members of a clinical team should be involved. In some units, advanced nurse practitioners may be empowered to initiate a TEP. This needs to be decided locally. Junior doctors ought also to be involved. Learning to implement the three Cs is an important part of the admission process. Whatever decisions are made about who initiates a TEP and contributes to its creation, the TEP requires to be endorsed by a qualified medical practitioner with four or more years’ experience. In most instances endorsement will be by the lead consultant. QUESTION 8 Can TEPs be used in the Emergency Department? In some hospitals in Scotland, TEPs are commonly introduced in the ED, and this is the ideal place. A TEP that is created early in a patient’s admission avoids the patient embarking on “the conveyer belt” of indiscriminate interventions that it is difficult to stop. Dr Calvin Lightbody, ED Consultant, Hairmyres Hospita,l has created a resource base especially focussed on TEPs in ED (podcasts etc). These are available online. QUESTION 9 Are there practical ways in which the barriers to TEP creation can be overcome? There are a number of practical steps that can be taken to improve TEP compliance: - Include a question about TEPs routinely in ward handovers. - Include TEPs as part of a Structured Ward Round template. - Adopt the mantra “no DNACPR without a TEP”. - Include goals of treatment (and hence TEPs) as a formal issue to be explored in morbidity and mortality reviews. QUESTION 10 How should TEPs be used in community hospitals? Community hospitals and Care Homes have specific needs that are not relevant in the acute medical or surgical unit. In particular, a Plan needs to facilitate the answer to the question: “If the patient deteriorates, should the patient be transferred to an acute hospital?” Almost always, trauma resulting from a fall should mandate transfer, but for other clinical events a personalised approach is required in making that decision. Both TEPs and ReSPECT are used in this setting. 3QUESTION 11 How should TEPs be evaluated and assessed, and is there any evidence to support their use? When implementing TEPs, ward based audit is helpful in addressing TEP use and compliance. This is usually about process. Measuring clinical outcomes is more complex. However, there is a growing body of evidence indicating that clinical outcomes are improved using TEPs. Non-beneficial interventions including ITU admissions, medical harms and complaints are all reduced in association with using a TEP. QUESTION 11 What about DNACPR? There should be no DNACPR without a TEP It is still the case that DNACPR orders are often completed without a TEP or a few days before a TEP. This is bad practice. Conversations about DNACPR in isolation are a bad idea. Deterioration for reasons other than cardiorespiratory arrest is much more common. Similarly, major interventions other than CPR e.g. Sepsis-6, transfer to ITU, are much more common. Thinking and planning for these is more practical and relevant to patient care. And yes, you can have a TEP without a DNACPR. DNACPR is problematic as a conversation starter: - Having a conversation about DNACPR in isolation often spooks patients / families if it comes out of the blue. The conversation is often difficult and can cause misunderstanding and distress. - There is a perception in the minds of some members of the public that DNACPR is code for “do not treat”. Avoid isolated DNACPR conversations in order not to damage trust. The TEP process includes relevant discussion which may be difficult but is more likely to have a positive outcome. 4