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uh, we have, um, Calvin and Gregor. We may have more people. Uh, can we see people? Six people on the screen? I think we have everybody back again. Um, and we had a lot of questions. We put it in in our registration. Um, packed. If there was a question that people wanted to ask, we tried to theme the questions a little bit because there was a lot of questions to get through. Happy for some additional questions in the chat box as well. Um, if if people, um, uh, want to something else. Um, So if I can maybe kick off, uh, question and answer session, um, about implementation. Um, I think we discussed a lot about implementing, um uh, temps, um, but in your practice, I think this one was kind of going to lease a little bit. And I may have really asked you this already. Um, but lease Robin, Jane and Calvin maybe lead to begin with what has been the common barriers, um, to, um, implementation of treatment, escalation plans. And probably a good one for you as well, Jane, but maybe kick off, please. Thank you. Stephen. Um, so I think it's Well, we have discussed, Uh, time is often, uh, one of the barriers because obviously, we will want to give our patients the opportunity for discussion and, uh, you know, staph shortages, so many different pressures and all of our clinicians, we need to take the time we need the explanation. So I think that is often seen as one of the barriers. And I think you know, that's why you know, I'm really promoting a sort of, um, multidisciplinary approach that everyone is involved in those conversations rather than it be. I don't mean just a consultant. I have no offense to any consultant. I don't mean it like that, but that actually these conversations can be started and then taken on by other people because people want to ask questions, and it's at that explanation. So for me, it's often time, But also, the other thing is that we are hearing from, um, some junior staff is Well, I don't know if this will be supported by anybody, and I think Robin sort of alluded to that in in his talk and some of the research that he's done. And actually, it is a concern that if our juniors are are saying that. Actually, they want to do one thing, but they feel they should be doing another. So I think it's a number of factors. Yeah. Jane, do you want to, uh, maybe? No. So, yeah, I agree. I absolutely agree. I think that there's the time factor. But I also think that some people are just actually really scared of having these conversations. And, you know, we have a lot, a lot of doctors who still have a feeling that you have to do everything you know. Well, I still have patients in their nineties being referred to our intensive care for them to make decisions regarding this. So there still is that fear of, of not doing everything you can possibly do and not realizing, actually that the amount of harm and amount of suffering that can come with that and actually the amount of work for people who really shouldn't be being involved. You know, intensive care teams should not be being involved in making decisions that award level for patients who clearly don't won't benefit from that that service. So I think I think there's it's brilliant. If you get other healthcare professionals who feel comfortable and have experience of having these conversations involved, um, and and and and actually sort of, those people who, you know. If there's a run in your hospital, a specific people who don't feel comfortable having a chat with them about what? What it is that stopping them from taking that forward. What, you know, is it a fear of litigation? Because some people are, you know, fearful that something will come back. But actually, it's much more likely to come back and haunt you if you do. If you over treat that if you actually treat appropriately. So um, that's all I would say, Gregor, I'm wondering I'm going to put you on the spot because we're both intensive this and I know it's, um it is, uh, such a help if the discussion has been had ahead of me turning up the ward three AM in the morning and there's a steer from the parent team, as it were, What do you think? Yeah, I mean, I think it gets back to the point around that, you know, everyone should have a tip. I think I think Well, what we've been talking about is changing culture, and that's tricky. But I think very much think it's what the project Robin had. An HS Lothian and and particularly for us, Steven turning up in the middle of the night. You're rightly through the notes. I quit. Winning. All of this is making the information visible front and center. And as I look at our track, their screen right now on my other screen here, I can see who's got a test on our H D right now, and when I click on their notes, it comes up in our significant information to have right there, and I've got its visible. And that's why people are using it, you know, more and more in in our healthcare setting. So that, that is the conversation has been had. That's precious, and we need to make sure that's easily accessible. So I think that's really important. Uh, maybe a question for, uh, Robin and Calvin was tools available to assist implementation? Um, assessment of tips. Where can these be found? Um, maybe Gregor come in at the end as well, because this fits in with the his work as well. Calvin, Maybe you might want to kick off. Thanks. So Robbins already mentioned the M and M Review. I think that's a really crucial way that you can show individual commissions, you know, patients that they may be familiar with, that they've experienced of what actually happened bit further down the line. And it started kind of non accusatory way where you can actually review what's happened. What I've seen really consistently. And certainly the things like the 50 case mortality review have done in Lanarkshire every year. The difference between patients who have had a tap and those who don't have a tap. You can see very clearly the differences and outcomes there, and not just in terms of reducing harmful interventions, but things that would be a good part of care, perhaps as well. And those conversations happened. So I think that's one really clear way. Also encouraging individual departments to carry out all the work, participate in some audits in my own hospital here, my ears and it shows where things have fallen off a little bit. I mean, we talked a bit about the culture change that happened during the pandemic, and that was about engagement coming from the top right through to the bottom and the education that happened along the way, too. So I know Linda finally asked about what Senior management can do. They can really help with that culture change as well, whenever it's emphasized that those things are going to be looked for emphasis, an unexpected of our staff as well. So Eminem reviews and also maybe things like introducing structured board grounds. I know some of the words and hammers have really benefited from a structured work ground sheet where tip is included in that and everybody who who's going to be looking after that patient knows what the goal of care is for that patient. And it's made clear and again when you get into that kind of situation where that's the normal practice. Uh, then the tools will follow from that for me. Robin, you're you're not muted. Are you speaking to you wanted me to join in? Yeah, I was wondering if the tools from your experience of implementation that are around I struggle with this, that I mean, I've shown you there's a video I did with the Med Aid department for illustrating how to conduct a conversation. It's not ideal, but just interjecting little bits of the of the of this complex approach a little bit about how to do it better. But on in NHS low. Then we have an Internet page devoted to treatment, escalation plan and the tools, the evidence base that having the conversation illustrations and so on. But, um, I think the culture change is not going to come through that level of education. The how to is goes much deeper, and it's about evaluating ourselves at a senior level. We've used M and M's, but I think increasingly we who have sort of allied ourselves with the treatment escalation planning program as a tool. But it's a tool in an end to deliver a change in the medical decision making culture primarily and the communication culture secondarily. And I'm putting them that way around because all our training, all our training in in post graduate medical education is devoted to excellence in in a managing a path of physiological process and back to it. Um, my greatest disappointment. And I think my greatest scope for change is that anybody else think if you're involved in Post graduate medical education case studies or evaluation of trainees, try to move away from the fact that the management of a stroke these days has changed dramatically as compared with 10 or 15 years ago. But you may know the protocol for the management of stroke, but every patient who presents with a stroke has a context, and there are consequences of intervening or not intervening. And therefore, knowing the guideline or the the latest guideline for stroke management is actually not the apex of clinical educators of post graduate education and an evaluation at the end of three or four years of S t 456 training. It's so there's the shift. I'm I suppose I'm disappointed that it's so difficult to shift our institutions, but I think that's probably the one that if I was devoted and any more years to this than I have done I would be aiming for is post graduate education and re because equipping equipping young consultants to come on board to practice well means exactly that. And at the moment, the good practice is still looked upon as dealing with disease, a mitigating disease, And it's not just that and many care of the elderly palliative care, they know that. But it's not the primary focus, or it's not central enough in the in dealing with acute medicine or acute surgery. Think Sarah Miller has put something in the chat box, Um, suggesting that these sorts of discussions and and thoughts around this should be incorporated into work place based assessments. Um, as there's really no replacement for actively doing it yourself, getting feedback, despite all the tools that may be out there. Um, Gregor. Anything specific from his, for example, about treatment, escalation or a C PS? Um, anything. People can go and have a look there. Yeah, so there's information on on the on the I hub Steven. As I mentioned in my talk, there's probably more information we have that on the I have. That's what we encourage people probably working within a chest Scotland to contact us because then we can share the forms that we have. I know some of the individuals on the Call me rob a bank most of the forms as well, but we can share them and put them in touch with people. And other boards have done this work, and I think it's been well said that the others. But the test is almost a ribbon that runs through every aspect of care. You're going to give the deteriorating patient. Um, and that's what we're trying to do. And so if you're looking at structural response to deterioration, test fits into that. If you're looking at how you, um, analyze your cardiac arrest data and you do medical reviews for your characterised cases. Texas The the tech part of that is key as well. It's an all of it. Um, so that that that should be there for you. Um, gee, maybe a question for you, Um, the information that comes in a completed step. How is that best captured? Doesn't matter if it's electronic. If it's on paper, um, and and and how do we capture what we're doing for patients that are considered for escalation and also those not considered for escalation? How do we do that? So, uh, it doesn't matter whether it's electronic or paper. It just depends what you have in your hospital, you know, ideally, we would all move to electronic and ideally, those records to be able to be seen wherever the patient goes next. So that you know, if you you would know on this admission What was discussed on the last admission? That takes quite a while in the hospital because we're still paper. And the main thing, the ones for a full escalation that needs There needs to be some kind of where you can very quickly find that information and then, you know, if they're not full, full escalation exactly what conversations we have on which bit of treatment are not appropriate. So, you know, Is it intensive care? Is it resuscitation? Um, and actually, for the frail ones, is it things like artificial feeding? And you know those sorts of conversations we have with the patients? So, you know, from a point of view of where you document it, it just needs to be somewhere where you It's the first thing you see. So for us, we open the paper notes do not resuscitate orders there. If there is one, um, and then the tip is behind it. Always the first thing you see. That's how we try to set our notes up so that, you know, in an emergency it's extremely simple to see. And then if they are full of escalation, that's all it needs to stay on. It Um and then But inside I I ask everybody to document the conversation that's been had just to make sure it's clear who's been who's had that conversation? Because I know there was a little bit about, you know, what about patients who, like capacity, came up in one of the questions earlier. And if we you know the patient's capacity we need to be having that conversation with, they're lasting power of attorney or the next of kin. You know, whoever their advocate is, and to make sure that, you know, and that that's documented because the biggest issue we have with them is if they're completed without conversation and and then something happens. You know, the patient gets really sick and, you know, unfortunately, they die. And then the family aren't aware that there was a ceiling of care in place and don't understand why they weren't escalated to intensive care or, you know, have a resuscitation attempt. So I all I ask because our patients move through different wards, you know, they come into the emergency department, they go to an acute assessment unit. Then they may go to an elder care ward. Then they may go somewhere else is that there is a very short documentation of who it's been discussed with and what the outcome was. Um, but it just needs to be really, really visible. And I guess the question to everybody is, where's the best place for this to happen? Galvin is e D. Can you possibly do that? Um, with with all the patients you have coming through, good everybody, you admit, have a temp in place? I think absolutely, I think any kind of conversation of this nature. You need to take any opportunity that presents itself. And for me, that opportunity as a patient is going to be admitted to the hospital, uh, would be an opportunity to have that conversation, make it document and make it visible. Like Jane said. I think it just may be at this point, there's been a few questions about primary care and about respect about the case. I would like to make it really clear these things are all the same nature they're not this and this and this and this they're all different things. That common thread that comes through all these things is an honest, realistic conversation with the patient and their loved ones were appropriate as they're not. They're not separate things. A respect for, for example, would very much influence a tip. And similarly, a temp could influence the respect as a patient leaves the hospital again. Those things for me have a common thread. Realism, pragmatism. Honestly, those things are coming through with that regardless of what what it is and making that so visible. Uh, shortening, Yes, absolutely. Taken every opportunity. Uh, when that presents itself to have the conversation and then make the results of that conversation visible maybe, um, one for everybody. Um, going back to what you just said. They're educating the public on this, um, or, you know, letting the public have that conversation. Um, it goes towards realistic medicine. Uh, you know, that expectation that what we do is patient centered. Um, and that's why we're having the conversation. How should that be developed? Is that a barrier? What do we do? I don't know who I'm opening that one to. Gregor has got his hand up. So maybe go to Gregor first. Yeah. I mean, I genuinely think, uh, we're very lucky in starting to have the realistic medicine program that was launched by Catherine called a Road Because we've got a National League for realistic medicine, we've got leads in most of our boards. And, um, you know, generally folks are realistic, and sometimes there are a lot more realistic clinicians, and it gets back to Robbins point about worry about time for the conversation. Often you find these conversations are a lot simpler and a lot shorter than you think they're going to be once you get into it. And actually you can leave it with a fuzzy feeling because you've done the right thing because you've been, as Calvin says, you've been honest and you've had a proper interaction with the patient. And and I think that through the through the realistic medicine program, we've got a good forum to talk about these things. And it's not just in the context of, uh, patient deterioration. And it's in the context of specifically anticipated care, planning for a whole host of things. Um, thanks. Anyone else? I think our public dialogue is really, um, in a state of paralysis at her, and there are three elements to this. One is first of all, the media have concentrated either on heroics and fantastic outcomes or catastrophes and dreadful outcomes. And so there's the There's the heroism of medicine. There's the shocking catastrophes that we acknowledge do happen and would happen less if there were Tepes. But if we take the public media together, the thrust is towards heroism and anything less than that in certain vault, in the places where there's in reason where it's actually discussed openly and outwardly, whether it's on the social media or in the press, that the conversation is skewed dreadfully by hard cases. On the other hand, that has intimidated our profession. We are not. We are not, uh either accustomed to or allowing ourselves to have a public voice. And the case in point was Matt Morgan, who was an I. T. U consultant in the south of Wales, who made a statement at the beginning of the covered epidemic about his attitude and his team's attitude to ventilation and the triage associated with ventilation. And the poor man was was pilloried for making the statement out. To my way of thinking, I thought it was an excellent thing to do, and it was very balanced and very appropriate. How are we going to wrestle with this whole business of limited resources for very sick patients in the midst of a crisis now. But it's just an example, and out of that comes a professional cowardice to engage with the public about this. We'd rather have peace and quiet than actually get to grips with it, and probably if we got to grips with it a bit more positively and courageously, we would find that there would be more voices in favor than against the trouble. Is that the moment, the silence on the part of our profession about these matters? I know I'm That sounds a very critical approach, but it's I think it's the truth and and I think the hesitancy to get involved publicly on the part of our of of the professions. If it's channel through the colleges or whatever it is, it becomes bland and diluted. It's very, very difficult and and I'm not. I'm not suggesting a solution, but I am suggesting a bit of reflection and meditation on what is what is our responsibility on behalf of our patients that have had a good medicine about of realistic medicine to engage publicly. There's complete silence in response to in response to that, Yeah. Did you want to say something more? Yeah, I kind of I agree with everything that Robin has said. I think I think the context we find ourselves in old nations of the UK particularly I think, I think are coated inquiries are going to be interesting and a covert inquiry. We'll come, we'll we'll touch on some of these themes. And I think many clinicians are feeling somewhat intimidated about what those inquiries will will will deal with. And obviously they're just getting going. And the danger is that leads to inertia. I mean, I think we need to keep pushing on this. I didn't mention it in my talk, but we're revising the same guidelines with the patient in Scotland, and that will have. It's not a secret that that will, that will deal with tips, and it will hopefully speak to use of tests within both seconds of care and and primary care as well. It's going to cover primary and secondary care to build. Make sure we're using similar tools for wherever you're you have your deterioration. Um, but I think I agree that we have there is always a danger of record this in this and the lack of honesty. And that gets back to the point that the misuse of DNA CPR is during the during the coated pandemic because we were using them as a surrogate for a poor man's test where we should be more honest about what the conversation was actually about. And that would be my view. I think it always comes back to having that open and honest conversation. Um, no matter how difficult it is, um, Lindsey has put a question, but it might be a good thing to finish off on because we're running out of time. Lindsey has put, um, what advice would you give to a student nurse about practicing treatment, escalation, planning. And maybe I just put that out to you all as a sort of a final comment? What? What is your advice to people that are implementing treatment escalation plans, practicing them on their boards? Um, and, uh, trying to establish This is something that that that happens in their area. Um, I might go around in, um, clockwise from what I've got, Calvin. Thanks. I'll give the same advice that I give to medical school. Uh, junior doctors as well talk to your patients, get to know them, get to know them beyond the diagnosis that they are. They're not just the pneumonia in room four. Get to know that their their background, who they were before they came in the hospital or about the context get to know what their wishes are. Get to know what important to them, get to know what they value and just be familiar with asking those questions and getting over some of the discomfort that they might be around talking about what happens next Because, really, that's what patients want to know. They want to know what happens next. That's maybe what they want to know. Maybe more than prognosis. Perhaps I'd also encourage you to read, to read Mannix, to read through and read the Taylors book. Listen to the talking mortality podcast of my of my own and and similar work around that area. So educate yourself as well. But most importantly, speak to your patients, get to know them being their advocate. Lease. Um, what's your advice? So so the same as calorie? Really. Patients are people like us, and when you speak to people. They'll ask questions, and it's okay to have difficult questions. And don't be afraid of those difficult questions. Um, and I think one of my colleagues then you know, said, sometimes it's so difficult, isn't it? When when our patients and I loved one speak to us about plans of care, but actually they want to have those conversations, and it's not right for us to not explore them because our patients sometimes are reaching out and asking for advice. I asking for guidance. So it really for me goes back to to being honest and open. And if you don't know, it's okay to say, I don't know, But it's not okay to say I won't find out for you. Um, so there's all sorts of people that you can talk to so just yeah, be open and honest and treat everyone as you would want to be treated. Gregor. Some final thoughts. Yeah, I would look at it from a quality improvement, uh, project perspective. I would say Just start to start doing quality improvement about around Texas, engage earlier with the quality improvement team in your local hospital and don't aim for perfect. Don't aim for all saying all dancing, electronic form. Get a paper form and get it on next to the old chart and start collect data and you will see improvement and look for the low hanging fruit first before, um, before everything else. Culture change is important, but get get the quick wins in initially that. That's what I said, Jane. So I think for nursing and medical students and people who are learning to find someone who does it well and and go along with them and then gradually sort of start taking over, you know, having those conversations because I think it can be quite scary as a student. And but actually, when you sit in a couple of conversations, you see how they run. Um, and actually, sometimes seeing the good ones and bad ones is not a bad thing, because you, you know, you learn how to do things better if you see how not to do some things sometimes. So I would say for, you know, get yourself a decent mentor, someone who can shadow who you know, does this a lot and and then you know, they will then allow you to start doing it yourself with some support until you feel really comfortable in in doing it. But the more as everyone said, the more you do it, the more open and honest you are with patients. Um, even if you can't answer all the questions just starting the conversation, then the more comfortable you become. Um, so thank you. I just may have finished Stephen just by saying, and I'm going to give you the final work. Well, I think it is genuinely important to consider our younger nurses and the younger doctors. And, um and I can you know what? When I set up the study about moral distress, it was because I was getting feedback about when I was teaching about steps. I was getting feedback about situations where these tensions were uppermost. And I think particularly younger nurses attending a ward round or an M d t. Feel as if they have no role and know part to play. And yet they're being encouraged in their professional development to be patient advocates. So there's this tension, I think, perhaps at a practical level, um, the culture of an M D T needs to be democratic and have a flat structure and what? Just one example in Lanarkshire In the world I worked in there, we actually started having the clinical support workers come to the MD Tea because they would be taking a patient to the shower or taking the patient, delivering the patient a tray of food. And, you know, somebody was Somebody was saying to the clinical support work, I'm done. And what are these doctors doing? And you know, when I was in the wardroom, they were perfectly polite with me and wouldn't tell me because I'm a consultant after all. And so I think, I think at a practical level, recognizing that the input about the patients state of mind, the patient's understanding can come from every member of the team, and that should be pulled at an MD the weekly or twice weekly MG T or on the wardrobe. That was a practical way in which we tried to democratize the engagement of every member, no matter how junior or senior they were. Yeah, absolutely. Um, in summary, I think communication is key. Um, and I I really hope that this webinar has given people food for thought and start or some extra ideas or or um, some impetus to start thinking about these conversations with their patients. I'm really all that's left for me to do is to thank our excellent speakers. Um, it has been really good having conversations. Been really good hearing your different views, your experiences. Um, there's been some really good presentations there. It's been very informative. Um, and I appreciate you coming and speaking at the webinar big thanks to me at all for helping us with the technology. It's amazing that we kind of I think we had 210 people in total from across just not across Scotland, but across many other countries joining us. And so it's really good. Um, I am going to put the feedback form in the, uh, um chatterbox, so it should pick up at some stage, and you can fill that in. You can. Also, it will be also sent out to you. So if you give us some feedback, that would be great. We will have additional catch up content after the event. Um, including, um, recordings from the presentations for you to watch again. Um, we'd appreciate your feedback. Um, would be great to hear from you with any additional questions or comments, and we can put those out. We will take your questions and, uh, add some feedback to that. So if you put in a question that will be in the additional material, um, and you will get a certificate of attendance after the after you've completed the feedback. I think at the start of all this, I mentioned the why I mentioned a bit of the water, and I mentioned a little bit about how escalation planning should be put in place. I hope we've given you some insight into that. Um, but I mainly hope that you can take away the how and you can use the how here to empower your patients, their families there, um, relatives, their their their their loved ones. Um, and you can use it as clinicians to to start the discussion about the future care. So thank you for joining. Appreciate your time. And maybe we'll have another one of these once. Me and Robin have a period of time to decompress from this one. Good to see everybody. Thank you very much.