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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. Okay, next up, we have, um, Robin Taylor, Um, Douglas at the chart. Douglas. Robin, Robin Taylor. Um, that's been mixing me up for many months, but Robin is a consultant. Respiratory physician. Um, he has been, um, involved in implementing tips for many years. Um, initiated the program and NHS like Lanarkshire in 2015. He's currently working in NHS lithium and up in N h s. Grampian with us. Um, he would have seen his name on a number of papers there, in in in California presentation. Um, he has, um, also authored the Exelon Review article that you have seen in your pre reading material. Um, Robin is going to give us a bit of an overview of, um, some of the questions that have been asked, but the general sort of, um, idea of different problems. Different questions that crop up when implementing steps. Thank you, Stephen. Um, can you just confirm that I'm being heard? And the slides are being seen? Stephen. Yeah. I can see your first slide here. You can see you down in the left hand corner. Very good. So I think my first comment in in in introducing this topic is, uh, covering It is to say how much I have admired Jane Snooks presentation as well as her courage. Um, you'll see that some of my comments are predicated on the fact that tips are applied selectively. And I just wish I could clone Jane Snook and apply her skills. That in every district general in the United Kingdom, because achieving and accomplishing a universal application of tips is so much more straightforward. And you have to do a lot less work at convincing colleagues. If indeed, there's a there's a platform of consistency such as she described. So, Jen, I just want to thank you for your encouragement. And maybe we could aim for that in the years or the months that lie ahead. So and I want to drill down a little bit. A treatment escalation plan is a tool. It's a communication tool. But undergirding it, there are two critically important dimensions that we've all discussed in various various aspects of them. In the last hour or so, there's the medical decision making and also the importance of thinking ahead. And then there's the communication with the patient and their family, the conversation content and the skills in conducting that conversation. And these are the tubes bedrock elements, and both of them need attention in training and education, and both of them are subject to huge cultural and professional obstacles. And I think there's a huge paradigm shift that's needed in what we regard as good medical practice. Realistic medicine, As you see here. It was launched by Catherine Calderwood about 5 to 6 years ago, and tips fit in snugly into reducing harms and waste unnecessary variation in practice, particularly out of ours, um, reducing harms and improving shared decision making. There are a whole cluster of goals under the realistic medicine banner that are addressed in a treatment escalation plan, but it's not the plan itself. It's the medical decision making, and it's the communication conversation with patients and families emerging out of both the conversation and the way we think about a clinical problem. We need to establish the goals of treatment and certainly in the treatment in the tip pro forms that have been associated with that's come up the four at the front end. If you like of a tip with a free hand box or a free hand territory that's in which we can set out. What are we trying to achieve for this patient? And what are we going to do if things get worse now? Traditionally, we've got a binary view of these things. We're either going for a curative intervention or palliative and supportive care. But I want to suggest there's a spectrum and in fact the majority of patients being admitted, particularly if they have multiple comorbidities the goals, maybe intermediate. So we realize that perfect health is no longer available. Maybe returning to baseline prior to admission is no longer available. But somewhere in there there's a modified recovery around which we can agree with the patient and their family, and that means certain interventions are appropriate and certain ones are not so. I just want to stress that the platform for our approach to constructing a temp is what are we trying to achieve and what should be done if things get worse and there's a range of possibilities there. Now my approach to this sort of training and education is summarized on the slide. Um, you'll see they're in the top left. Traditionally, we concentrate in a deteriorating patient on what is causing the deterioration, the path of physiological process. Uh, my father died of Hypercalcemia, the hematologist, two days after his death, apologized that the Hypercalcemia hadn't been brought under control. But in actual fact, the context of my father's illness was that he had a relapse in lymphoma. His life expectancy was 1 to 2 months, and the consequences of having successfully controlled his hypercalcemia are unknown. But I'm going to suggest, given that he had a very dignified and comfortable death due to acute uremia secondary to the bio chemical disturbance. That was an important way in which I'm illustrating but the consequences of intervention as well as the context. And Calvin has emphasized these things. Not just the path of physiological process are the things that we ought to be grappling with in terms of clinical decision making. But then there's the other dimension, and I'm going to come back to a little bit more on the subject of the conversation with the patients, particularly in the acute setting reflection on the past, anticipation of what might lie ahead. And what happens if things get worse and the outcomes that may or may not be anticipated if we intervene there the basis of the discussion. So you've got your discussion. You've got clinical decision making based on these top three issues on the top left, and together they form the basis for the goals of treatment and also critically harms avoidance. Sometimes every once in Nephi to have said to me, um, can we fill in a Can we start creating a tip if the patient has no capacity and the family is not present? And my response is, we have a duty of care. We have an ethical responsibility to avoid harms. And if, in the absence of a tip in a serious deal patient, there's the likelihood of inappropriate interventions when they go off shift or out of hours, then a tip is appropriate and is important. Harms Avoidance is a critical dimension of what we're trying to achieve wherever you're working. I hope that you've worked on a set of guidance notes or a standard operating procedures for for tips. It is a complex matter. The indications for Tep. And if you're in Essex, then it's for everyone who does what the role of staff. And we've already hinted that or more than hinted that everyone should be involved at a particular level in Lothian. We're encouraging all junior staff to be involved. But the endorsement of a tip is for registrars and consultants. In the guidance notes, we need to know about important mega medical legal considerations. The Montgomery case, the Tracy case. They all have an, um, bearing. They're not front front stage, but we need to know about it. And then we need a road map for the completion of the tips. So guidance notes are important. I use them in a paper format for teaching small groups currently in Aberdeen Royal Infirmary, and I get them to read the guidance notes before I open my mouth. Um, just so that everybody is on board, uh, to begin with with what are the critical issues? I'm going to say a little bit more about training and education. There are three groups. Group number one here is the senior charge nurses and nursing staff, and that emphasizes the importance of TEP in the context of early warning scores and recognizing the deteriorating patient. And then another important bit is about this is to try to get us to shift away from the importance of DNA CPR to the importance of a tip. And traditionally, nurses are very keen to have a d e n a c p r in order of the patients unstable. But frankly, although it's got a roll, the provision have a temp. The goals of treatment. What should we do if things deteriorate are even more important than what should we do if there is a cardio respiratory arrest? That eventuality is rare by comparison, with a drop in the BP or a bleed, or whatever it is for the junior staff. Um, we give guidance about when and how to create the tip. Who, where are the levels of responsibility? What is the content of mentioned goals of care, but the other content in attempt that should be annotated in some form? or another is the patient's understanding. We've talked a moment ago about the patient's understanding and again mentioning DNA CPR and trying to win all of us away from DNA, CPR and the unfortunate roll that historically it has and and which, and we pick up the tab for that because it's become a proxy document, Um, for for limiting treatments in some way, let's get away from that. Let's get it explicit and clear and personalized in a tip and not have it somehow or other implied by just having a d e n a c p r For hospital consultants, these are the greatest challenges of them all. Um uh, and I think it's because in post graduate training and particularly among all the consultants, decision making has become a matter of pattern and habit. And there are cognitive biases, which I'm going to come two in a minute. I find it's sad that we don't see her arms reduction or harms prevention as an important clinical goal. Premium No, no, Kerry has slipped away from are the center of our radar. Um, Calvin like body has already talked about the fact that time that a tape is time well spent. One of the problems in assessing how tips operate and how what are the outcomes is that for the for in many situations, the tip is designed to prevent something happening rather than for it to be active, actively pursued. In other words, measuring outcomes. I'm going to come to this in a moment. Measuring outcomes is really difficult because because we're measuring things that don't happen. That's why Calvin, like Body and I concentrated on nearly 300 patients in the study. We did in 2017 18, and we concentrated on harms and harms reduction. But it's difficult to convince the convince one another as colleagues that tips have a benefit because you don't see the benefit. And that's the point. It's about avoiding indiscriminate interventions in appropriate treatment choices, particularly out of ours. And lastly, for consultants, I think it's important for consultants to create a permission giving environment for the whole team, particularly trainees and junior staff will not engage in in treatment escalation, creation, treatment, escalation, plan, creation unless the consultant team in that unit has agreed that this is the thing that we are all on board about. If there's doubt about that. Then we can be sure that junior staff hesitate to put a tape in place. During 2017 and 18, I was finding my self frustrated and disappointed by the impact that tips were having in NH Islamic Sugar and I embarked on a coaching, uh, to I visited 100 and 69 consultants one by one, and I had a structured coaching hour, which focused on What are your personal one of the personal elements in your character in your temperament, in your intellectual, uh, capacities that make you decide what you decide when it comes to individual patient's treatment and management. There are a whole list of cognitive biases that are out there, and I think we need to understand this. I am a lot more sympathetic to my colleagues who are unhappy about tapes are just in different tips because there are all these things that militate against treatment, planning and particularly for planning in advance. Uh, there's the aversion to death and dying. There's the doom and gloom. I like to be a positive person. There's the addiction to the curative medical model E. I'm just here to sort out the coronary arteries or to sort out the, uh, the bleeding points or whatever it is. We are not just biological technicians. There are those who find uncertainty really difficult to cope with, and therefore they give the patient the benefit of the doubt by intervening, even although these are almost certain that the interventions are not going to be beneficial. There are personal experiences, uh, where success with one patient becomes the model for using the same interventions for a host of others. And last chance medicine, as I call it, kind of can be successful. And then that leads to what we would call confirmation bias. Um, we do some reading, and we read in a journal that such and such an intervention is jolly good for such and such a disease. And lo and behold, we start adopting it. That's information bias. And then there's moral justification or the moral, a moral sense of failure when we intervene when something in our unit is characterized by over treatment, more so than undertreatment or both apply, but more so. It's the overtreatment situation. I was only doing my best is the moral justification. Well, you were only doing your best. We're only doing our best if the path of physiological process has got a singular priority. If we have a much more holistic view and we look at the context and the consequences, then quite frankly, sometimes the judgment I'm only doing my best doesn't really wash. Risk aversion. Junior staffer involved in, uh, they avoid criticism, and I'm going to come back to that. And then there are the institutional pressure's. There are the perhaps poorly described pressures that we feel in a particular hospital or a particular award to behave or conduct ourselves in a particular way, and that overrules some of the instincts, some of the compassion, some of the understanding that we have and we comply with the system in the institution rather than step out of line. All of these things need to be owned and acknowledged they are problems. Junior staff. I've recently conducted a study in among 21 F. Y to use in the Royal Information Edinburgh, and, uh, we posed this question in my present situation. My approach to medical decisions out of virus is influenced by having to do what is expected of me rather than what I consider to be the right thing, and 15 out of the 21 agreed or strongly agree with that statement. In fact, they were given case studies and the case studies five case studies, and they were asked to choose out of five management options, which was the right thing to do and which was the expected thing to do and 53% of the time, the right thing and the expected thing. We're not the same now. There's something terribly wrong when our junior staff think that the right thing to do and the expected thing to do or not the same and they proceed to go with what's expected and the consequences. This thing called moral distress. We could avoid that if we put a treatment plan in place, which reflects the consultant and the team decision on award round or it's an MD tea meeting. Okay, how about a little on integrating tips into existing practices? Gregor McNeil has highlighted the importance of weaving treatment escalation, planning into the deteriorating patient protocols, but there are other groups in whom we can, uh touch and reach theirs. The hospital at 19, and their protocols there's and notwithstanding, what Jane has told us about what goes on in Essex. Um, there are a few groups or situations in which I have identified that tips can be used mandatorily with everybody's agreement. Frail patients with trauma The 85 year old with the fracture in the next, uh, femur all HD you admissions we We adopted that in Saint John's Hospital and Lithium, and similarly, one of the problem areas in one hospital I worked in was medical borders where medical patients were boarding out in OBS and Gyny, or gynecology awards or surgical wards. And they were they were receiving less attention than they ought to have done. Some of them deteriorated. And so, uh, in one word, it was mandatory that if a medical border was being admitted from a medical word to a surgical ward, then they had to have a temp. They had to have a temp. So there are places where mandatory tape use is easy and organizationally straightforward. Um, then there's the structured ward round. If you if you have medical wardrobes or subject wardrobes where that's in place as a template, you can include tips in that and then importantly, morbidity and mortality reviews, and I'm going to mention that in just a moment. So when we come to look at tips and say, Are they working? Are they doing what they're meant to do? We have to think of two dimensions. There's process and there's outcomes. So in quality improvement audits and so on, we can look at the frequency of use. Was the tip present or created when ought to have been? Was the test completed satisfactorily? Was the tip used useful to out of our staff when the patient deteriorated? Was that put in place along with the D. N A. C P R. Was the DNA CPR used alone? These are questions about the process, and they you can pick one or more of them and use them for either nursing or junior staff audits, and they then in turn, can be used to improve performance. Um, here's a template. I'm not expecting you to be able to read it all, but it's available in the slides afterwards. Here's the template for an audit currently being used in NHS Lothian among F one f Y. Two, and the key issue here is not just Was there a temp But what were the goals of treatment in the notes? Where where was the tip? Annotated with the goals of treatment. And then you can see lower down what elements of the tape were completed. Well or not. Well, this the this is you. This is being used, uh, catch the sort of population this is being used for our picked up the huddle. And if in the huddle there have been overnight medical emergencies, then these that's the group of patients for which this template is being used. It looks complicated. It does need a bit of tuition and training in order to use it. But I'm just giving you an idea of what can be used to evaluate process. Then we've got outcomes. Now Calvin, like body, has given us some of the outcome measures in terms of the evidence base there are before and after studies studies before it was introduced or and then what happened in the subsequent months or year. Or there's you can have comparative groups, people with and without tips of these. But a Calvin has mentioned harm reduction and complaints, referrals and transfers to H. T. U R I t U and we did a study in Lanarkshire on the inappropriate or appropriate use of IV antibiotics, and we showed that in patients who were at the end of life, 7% of patients with a tip had inappropriate antibiotic use on the last 24 hours of life. And that compared with 34% in those who did not have a tip and then their staff satisfaction. So there are a variety of outcomes. So when you're if you're taking on board the idea, yes. Is this working in for working in our area? There's there are processes and there are outcomes. It is complex. It is not easy, Um, but just be aware of the distinction between the two in terms of justifying to yourselves or to the wider hospital in which you work. Why are tapes good? And why should we improve? I'm I think it's fair to say that accountability in tips use is still something certainly is my experience. There's something there's a hesitancy about it. Should we? How do we encourage people? Is it carrot or stick? And one way that's been mentioned already is to incorporate tips into the morbidity and mortality review process and I've got two slides here. This one is talking about what were the goals of treatment. And here we're back to the fundamentals. If a patient is admitted and let's go say goes to theater because of, let's say, a sub acute bowel obstruction. And they're frail, often the post if the patient's dies, the post mortem evaluation is about what were the technical dimensions of success or failure, what went wrong and what went right in terms of the service delivery. But if you include goals of treatment into your Eminem process, you're actually taking a step back and you're saying, Well, what were the goals of treatment? And we're the appropriate. And should the patient have gone to the theater in the first place? And similarly, if I go into the next slide, you'll see here that, um, we've got, uh, Eminem Review, and this is an extract from the Lanarkshire one. Um, again, it's just was the tape in place and was it when was it completed and what What was it? What was its role in relation to DNA CPR? So I think we need to move to a little bit more of of the the accountability end as well as as as much as reinforcing implementation. And I think probably a good starting places, morbidity and mortality reviews, not just looking at what people did, but why they did them and if what they did for a patient was appropriate and consistent with realistic medicine objectives. Finally, I want to talk just a Jiff for a Jeff about a moment about prognostic conversations. This has been mentioned already my own experiences that they don't take half an hour. And when? When? When the challenges. I don't have time for this. I personally don't agree. Um uh, My approach is to try to get the patient. First of all, let's say we'll call him George George. I need to talk a little bit. Not just about your treatment, but maybe about what might lie ahead. And And, um, that's of course, the moment when sick enough to die can creep into the conversation. I get the patient to reflect on the trends, the context often that in the hospital twice or three times in respiratory medicine where I work, they often have COPD, and they've had two or three or four exacerbations. You can get a patient to reflect on the trends very sensibly. And when you say this is the way things have been going, then you can get them to instead of looking backwards to look for words. And that gives up what our our expectations. What are we trying to achieve here? What's going to happen if we do intervene with X or Y or Z and is that desirable and critically? The question. What should we be doing if things get worse? There's the trend in many patients with multiple comorbidities, it can be cardiac failure, respiratory failure, and we see them when the blue or the green bubbles there whenever they have an acute exacerbation. But in actual fact, they've been deteriorating over a period of time. And bringing that in to the forefront of the patient's mind or just asking questions, which allow that to happen, gives context to the conversation as much as anything else. So, John, what are your thoughts about the way things have been going lately? Your breathing isn't as good as it was. Does that worry you when it comes to thinking about what might lie ahead? Here's what I think we can do for you and what we try to achieve. What are your thoughts? What is your understanding? Was a good question raised earlier on. We will do our best to get you well again, but we need to think about what we should do if things were to get worse. What do you feel most? That's a cluster of questions that I've used, particularly when I was doing acute medicine and acute respiratory medicine. And if you'd like to see a video on this topic, um, I've given you in bold numbers and letters there. There are no spaces, but just in order to copy it down or get access to it, it's a freely available, uh, female uh, recording. It's about 12 minutes long, 30 minutes long on the key elements of a conversation. And I'm not for a moment saying it's an ideal, Um, it's actually widely criticized, but just as a sort of way of getting into comfort with these conversations in the acute situation and in a short period of time is a good idea. So what happens when there is no tip? I think that's the greatest challenge we offer to our colleagues. Junior staff deliver expected rather than right decisions. There are non beneficial interventions in harm's importantly, if we're focused on correcting hypercalcemia rather than the fact that a patient has an end stage lymphoma, then there can be neglected palliative treatments. So tips are about making it easier to do the right thing. There's these are sort of advertising slogans in NHS Lothian tips, making it easier to do the right thing. And the other one we've got is no DNA CPR without a tip. So thank you very much indeed. And I'll be happy to take some questions. Yeah, Robin, there aren't direct questions yet. I imagine someone will come through. Um, I guess one of the questions I had was that you were talking earlier about the junior doctors tending to um towards what is expected rather than what is right. Do you think we all do that? Do you think we do? That is senior conditions as well. We think that the what's expected offices, too, go all guns blazing when maybe it isn't the right thing to do. I think I think I think we may feel that way. But I think as with with as the years passed the expected and the right thing, merge into our merge into one another and become established and fixed in our minds. Steven. I think it's more of a dilemma for the junior staff who, particularly if they're just out of med school or they have a sort of altruism in their minds, and it's its challenged when they're faced with this dilemma. I do the right thing or the expected thing, so I think it's I think it's just with the passage of time. We tend to think that what we do is both expected and right, and they're one and the same. But it's not true. And that's the challenge to more senior clinicians. To get a grasp of that and to be willing to be challenged as to how we make our decisions in practice medicine. That's why I think there's a paradigm shift needed. And the paradigm is to say, the paradigm that needs to be abandoned is to say that aiming for a reversal of the path of physiological process is always number one priority. I think we need to ditch that in favor of the new reality. Um, William has put, uh, I think it's more common rather than a question William Anderson about during cove it when there were a lot of sick people around, people became more comfortable, Um, suggesting appropriate steps because they were exposed to it a lot. Um, I suppose that goes to the question about treatment. Escalation plan for everyone. Um, is that worthwhile? Or should it just be for the deteriorating patient? Well, I think I'm actually an agreement with Jane Snook. I think it should be for every patient. And one of the things we've got during the coated, uh, emergency of 2020 was a glimpse of what life is like when everybody has a tip. Because that was certainly true in NHS, Lothian. Everybody had to have a tip. But the we've drifted away from that, uh, and I suppose the incentives of the coated epidemic are no longer. It's a pretty and I This is why I admire Jane Snooks approach. Why is it why? Why did why have we drifted away? Maybe we need to re examine that in various of our, uh, leadership teams in the various NHS boards. Um, Fiona Finley and I think, uh, hero's question as well. Maybe kind of go together. So Fiona has asked the role of senior management team supporting, um, this area of practice and and Paula has said about the incident management. So I guess clinical governance and looking at, uh, focusing as much on harm and over treatment as under treatment. So it's actually probably maybe questions. But why do we do that in a M and governance style? Um, and you do the senior management team for that? Um, I couldn't agree more with Dr Finley there, Um, this needs to come from the bottom up and the top down and in the in the absence of top down, Um, in the absence of very senior support and I have to say I've had that but I've I've sought it. I think senior management teams need to make it clear that this is bored policy or hospital policy and adopted at that level such that bit by bit as people take it on board. They are seem to be practicing in the normative way, and those who are not taking it on board are the outliers. Rather than having champions who are sort of isolated fanatics or reviewed as such and everybody else just carries on as normal. So I think senior management engagement and promotion is absolutely vital. Um, to the to the long term success of a step program. And I mean, to be honest, what is the what is their? They already embrace a early warning scoring as and and electronic mechanisms for identifying the deteriorated patient. Why are we doing why we're doing half of the job? The response to the deteriorating patient is identification and then management. So the management element is just as important as identification. And that should come from the top. And there are a couple of questions about tips. Um, not just in the hospital, but out of the hospital. Is it something I'd like to get your a few on? It's something that should be done in the community as well. Um, is it something that fits in with primary care? Um, discussions. Um, well, I'm not in primary care, so I'm not I'm not qualified to comment. I am qualified to say that, um, in my outpatient setting with advanced lung disease, anticipated care plans have become part of my practice. And I very much welcome interaction with primary care in terms of trying to set up an A C P for a patient safe with advanced COPD or advanced interstitial lung disease. Um, I think I, in one size does not fit all. There was a question earlier on about community hospitals, and when I was in Lanarkshire, there was a test which was modified for community hospitals because they're the key issue is whether, if the patient deteriorated, where they're going to be transferred back to the acute hospital and the same thinking applies in rest homes and care homes. So there's horses, for course, is, um, I don't think one size fits all, I think one informs the other. And certainly I think it's fantastic when in primary Care and a CMP conversation has already been had because then it doesn't take the patient by surprise when others in the acute setting, when the patient is deteriorated in the community and is transferred into hospital. When if somebody picks up the conversation there and then and it's already been part and parcel of the patients thinking before they come in, then you're at a huge advantage rather than having to start fresh and oh my Oh my goodness, this is a great surprise and a bit shocking. So I think we've all got a part to play