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um uh, GN stuck. Um, Jane is a consultant or the geriatrician who works in the Princess Alexandria Hospital in Harlem and Essex. I believe I've got the right place. She has introduced steps across the entire hospital, and after a bit of a slow uptake, she went down a slightly different routes. So I shall teach you with that. And I shall leave Jane to do her presentation. Thank you very much. As you say I'm from and I work in England. I work at Harlem Hospital, and I've been very much involved in Tep forms, Um, introducing them into Princess Alexandra Hospital around about five years ago. And I was very lucky that at that time I was working with senior colleagues who really understood how important this was. And I think that's crucial to making test forms be properly rolled out throughout the hospital. Um, I'm just going to go back. Sorry. I'm just going to go back to my first slide just to explain exactly what I'm going to go through. So, um, what I'd like to talk about today is actually some of the questions that we have been raised by the group. So the first question is, should every patient have a treatment escalation plan? Um, how to get medical staff involved? So how to get people really engaged in this? How to encourage colleagues to complete them, especially when time is very limited and especially at the moment, you know, we know are any departments are absolutely overwhelmed. Um, and you know, do you have that extra bit of time to talk to patients about treatment, escalation, how best to capture the information. Although everyone has different types of forms, there is some, you know, simple things you can do to make sure that the form is easily completed and when to review the IEP. And obviously I'm happy to answer any other type of questions. But these are things that I was going to focus on. So the first question really is Should every patient have a step and I would say yes. Um, every patient over the age of 18 should have a tip put in. The reason for this is because if you don't your then you're having to decide. Does this patient need a step or don't they? And then there will be people who will be missed so You know, some people may say, actually, there should be an age cutoff for a frailty cut off for treatment escalation. But I don't agree with that because I think as soon as you start adding in any kind of choice, then it just doesn't happen. So what we did at Princess Alexandra was we said that actually, everybody who comes into hospital is over the age of over the age of 18. We should be checking with them about their healthcare wishes. We should be finding out if they've had any, you know, pre plans put in place in advance care planning. Um, and if we if you do that, then you can make sure that the forms are properly completed. Those conversations I had I have a lot of patients who come in the hospital who physiologically actually look really well, especially the patients around sort of early eighties. But when you actually talk to them and properly, you know, assess them and have open conversations, they don't want certain treatments. They don't want to be put through resuscitation techniques. They don't want to be put through an intensive care stay. What they want is they want good health care they want to be, you know, reversible causes treated if they can be treated. But actually, if they deteriorate despite those treatments, they want, you know, dignified, um, care at the end of their life. And when you start having those conversations with patients right at the beginning of the pathway in the hospital or in the community, then actually they feel much more engaged with everything else you're going to do. And, you know, with our patients who are young and fit, the question I ask them is, Are there any medical treatments you wouldn't be willing to have? You know? Then it captures those patients who don't want things like blood transfusions or other treatments, and it captures those people who are already made decisions. So even if I have a 56 year old patient coming to hospital, who's, you know, suffering suffering with pneumonia, who I think would be perfectly appropriate for all escalation, I'll still just check that they they're happy with that. And for the older group, who actually often are appropriate for full escalation, talk to them about those things. Uh, and actually, often I'll say to them, you know, if your condition changes. Are you happy to re discuss this? And it just starts me, meaning that people are having much more open, honest conversations. Um, and it does also mean that you can talk to people about the benefits of harm, harm of treatment. We all know that intensive care treatment is extremely harmful in many patients. You know, it may be extremely beneficial in others, but for some it may leave them. Either they don't survive the stay or they come out of intensive care in a very, very poorly condition. And we need to be selecting the right patients for those treatments, making sure that patients who are willing to have them and they are going to benefit the most. And and so I think that, you know, every medical consultant, um, should be having these conversations with the patients. I'm a Ortho geriatrician. I look after patients on a hip fracture units, so I look after the medical care of a lot of orthopedic, frail patients. I don't have a lot of time to see them before they're surgery, but we have these conversations with them before they're surgery in order that the right patients are getting the right treatment. And if they deteriorate during their operation, which is often not the time they do it often in the period. You know, after the surgery, they have problems. If they deteriorate during that time, we have a plan, their family know the plan, and we can make sure that they get the right right level of care. So I'm a big advocate for saying that every patient should have a tap. It opens up dialogue, but it also means you're not having to arbitrary decide. Should this patient have a tip, or shouldn't they have a tip? I'm just going to move on my slide. The next question when the next point I want to raise is how to get medical staff involved. And what I would say is it's selling it to those who are most affected, affected. And that's the people that work not during the normal 9 to 5. So for for treatment, escalation is extremely difficult to do it when the patient is, you know, very, very sick in the middle of the night. You know, a doctor working on the ward's it's called to see a patient with a early warning warning score. That's seven. The patient, um, is deteriorating rapidly, and they are then left to make a decision. You know, with the patient and the family about where to go next. And that's just not fair for that doctor. And it's just not fair. For the nurses on the ward, those decisions need to be made in the clear night of the light of day. Now there will be people who deteriorate at night who offer full escalation and appropriately and then raised up to, you know, intensive care. But there will be lots of patients with these forms are not in place, and it's not been discussed who will deteriorate who aren't appropriate for those treatments. And then it's extremely difficult for out of ours doctors and nurses to be managing that. It also means that the patient and the family aren't aware that there's a risk of deterioration, which puts them in extremely difficult position. The patient then dies. There will be significant bereavement issues. So what? When I talked to so regularly, I'm I do end of life discussions with with the staff members, and I do teaching on this, and I'm always sort of saying to the consultants. Please do this as soon as you can have these conversations, and I'm saying to the junior doctors, Please insist that your consultants do this. Please insist they have those conversations and each what I do a white board around every morning through all of the patients in my ward area. And if the patients don't have a TEP, then the the nursing staff are telling me. So they say, Oh, this patient needs a test form and it's an automatic. The automatic that they need it. They're over 18. They need a step. It's not. Should they have one or shouldn't they? They need it, Um, and that just means that the right patients are receiving the right treatment at the right time, and I know that that's something that's already been mentioned. But this is the crucial part. We don't want patients suffering having treatments are inappropriate if the patient's deteriorating and aren't for intensive care, aren't for escalation, and everything has been done that that we can do to treat the reversibility of their condition. Then whoever is on you know, whoever is then dealing with that patient as they're deteriorating will know that they should be having the conversations about end of life care. So to encourage your colleagues to complete them, they need to be part of normal life. They need to be part of, you know, normal clerking and post take. I say to them. I actually say to her the juniors who are doing the clerking If you see a patient in the emergency department, just ask them if they've ever had any advanced directives put in ever had any community do not resuscitate orders. You don't have to. If you don't feel you can discuss these things with the patient. It's just asking if they've ever, if they have any, so that we know I don't know what your patient records are like, but we don't have a good integrated healthcare record. So every time a patient comes in to the emergency department, I don't know if they've had they've made any prior plans for you know, any of their advanced wishes. So we need to ask. So I just say to the juniors, Just ask. It's you know, it's just part of the clerking, Um, you make it part of the medical plan. Ideally, they shouldn't leave the emergency department without a treatment escalation plan. All of our notes have one in the front. They're not always completed. So we're not doing this wonderfully with trying and with the increased pressures, I'm getting more and more patients coming to the wards without treatment. Escalation plans completed, and so, as soon as they hit the walls were doing them. But, uh, we're just it's just ongoing education, ongoing reminders. But every set of notes has a treatment escalation plan in it. And, um, then you get the rest of your multidisciplinary team involved. As I say, the nursing staff really, really appreciate having having the information, having it documented and knowing where they stand with the patients if they become unwell and knowing what the patient and the family knows. So get get anyone involved. You can to help encourage the consultants to be completing these. Our form is quite straightforward, so there will be lots of different forms. Um, but you do need a separate form. So in our notes, which are still paper, we have the if you if you have a do not resuscitate order, you'll have that in the front of the notes and then behind it is the treatment escalation plan. It just makes it so, so much easier going back to the question of should everybody have one? If you know that everybody has one in your hospital as soon as the doctor on call or the nurse, uh, with a poorly patient, they can go straight to the notes and they can find that form and they can see exactly where they go next. For the patients who have a full escalation, we have a box at the top of the form. So is this patient for full? Do they? Are they full escalation? Yes or no? And then, if know, do they have capacity to have conversations about that decision? And if know, who has it been discussed with? And then if know what treatment is appropriate and then inside? We always ask people to document the conversation they've had because that makes it so much easier for the next person coming along to to review it. Uh, so our forms are not complicated. Um, they have a they also we have incorporated a mental capacity assessment on it, just in order that that can be assessed as well, and then when to review the IEP. Um so I would say whenever the patient's condition changes or when new information comes to light. So, you know, we have a lot of patients coming in with with cancers with palliative cancers, but we don't know until we get the information from the oncologists. What? What? You know where they are in their their their their cancer pathway, you know, is this Is this a new diagnosis of palliative cancer and there's a lot of treatment they're going to receive. So, you know, if you have prostate cancer with that steamed palliative because it's not curative, you could still be, you know, alive 10 years later, um, and still be very appropriate for full escalation, whereas other patients may not be so if you if you you know, you talk to patient about the escalation plan and then actually a lot of new information comes to light. Which shows you that the patients a lot frailer a lot more and well, then you first thought, then you at that point, you should go back in and have further conversations with them. Um, and you know, I've had patients come in who have come in with falls hip fractures who have seemed actually clinically well, not particularly frail, but then postoperatively. It's been clear that they are actually of frail, and then we initially thought, And then we go back in and have further conversations about escalation. Um, so I would say it's not something that needs to be reviewed on a daily basis, but it's something I always review when the patient comes to me. So when I'm the clinician taking over that patients care and then when there's any change in their condition, that's all the questions. That's all of the slides that I had, Um, I have for you today. I'm very happy to answer any questions about anything that I've brought up. And I will be around at the end as well for the question and answer session. And I just want to say thank you very, very much for the team who invited me to do this presentation. It's something that treatment escalation is something that's very, very important to me and very high. I'm very happy to share my experiences. Jane. There are a couple of questions in the chat that you've you've covered some of them already a couple of questions that are around How, um, tips and, um, a c ps anticipatory care plans integrate. And do you have patients that come in with a C PS in place? And, um, is it does the tip add something extra to that? So we do. Um, and I would say that the tip does because the A CPS can often be quite not very specific to certain treatment. So it's more. The advanced care plans are often about patient sort of wishes. But not in a very is this person Is this person for this treatment or aren't they? So even if you have an advanced care plan coming into the hospital, we would complete a step. And our tests, actually at the moment are really only specifically for their hospital stay. So, you know, on our treatment escalation we have Are they for resuscitation? Are they for escalation to intensive care? Um, are they for blood transfusions, oxygen, arterial blood gases, that type of thing. They're quite specific to hospital. So I would say when they come in, if they have an, um, an advanced care plan, we would use that to help us with the conversation with them about the treatment escalation plan. But I do think it's worth having the treatment escalation plan as well, and that the treatment escalation plan doesn't go out with them when they go into the community like the do not resuscitate order does for certain patients. We will also put things like peace documents in place as an additional advanced care plan. Um, but I think I think I have having the tech, which the hospital staff are used to. It is really helpful in that time of emergency. And although the document doesn't go out at the end of the patient's day is the fact there was a step in place communicated somehow to the primary care physicians. So what we what we put in on our discharge summaries is what the treatment escalation was. So if they were full escalation, that just goes, you know that goes on there. If there was a do not resuscitate order, we would normally also put that they were for water based care and not for I t U. That, uh, that does need to be improved for us. I'm not sure exactly how well it's completed. There's a question about whether a step is purely a medical form? Or is this something a conversation that can be started by or led by the Allied Health Professionals? Yeah. So I would I would say all these Whoever is whoever has the most experience and has the best report with the patient can start the conversation. So in our hospital, that kept decision is so if you're going to limit escalation for a patient, uh, it has to be made. The decision needs to be made it register our consultant level. But I think anybody can start those conversations. And certainly And, uh, you know, I was doing some training, uh, in the hospice for our advanced health practitioners in the community. Um, they're they're trying. They're they're being trained so that they can complete do not resuscitate orders. Um, in order that you know, they were often having the conversations and they will start the forms, but they then need to go and find a general practitioner to to sign them. And this seems completely crazy when they're the ones who actually having those open, honest conversations. They have the experience to do it. So I would say depending on your hospital. You know, if you have advanced care practitioners who are already having this conversation is whether the hospital will then allow them to to do the full form or whether they still need to sign off by a consultant or registrar. But I I personally, I think it's whoever's best place to have the conversation. And often that is, uh, that, you know, often it is people who aren't doctors. There is a question about, um having, um, an ethical support team. I guess they're for both patients and clinicians themselves. Is there is there support that should be in place for for For for people, putting tips in place and for the patients if that discussion has been had. Um, so in our hospital, we do have a A clinical ethics committee. Um, I chair the clinical Ethics Committee. We get very few referrals for anything like this, but I think having someone you know, having so our clinical ethics committee is made up of a multidisciplinary team. Um, during Cove ID, we we used to meet regularly during coated. That's sort of reduced significantly. And now what we do more is offer a service where if there is a particular issue. We will then try and form a group short notice to discuss it. Um, I I think you need. So if people are not used to completing these or, uh, they they're finding it very difficult to have those conversations. I think, um, there is a lot of training around breaking bad news about, you know, difficult conversations if they find if they're finding that difficult, but having someone in the trust who you can speak to about it. So I've always been a big advocate for treatment escalation. I'm always happy for any of our, um any other doctors, nurses or anyone to speak to me about it if they have any particular concerns. So having someone in the hospital who has an ethical background and can help with those conversations, I think is extremely useful. And there's a comment. Um, I may have lost about having a non clinical person their role for chaplaincy, for example, um, supporting the patient through this, which I guess you would support as well. Absolutely. We have amazing chaplaincy supporter at our hospital were really, really lucky. I What I would say is from the majority of patients. This is quite a straightforward conversation. Um, and there and I say the majority of the elderly patients that I look after the average age of the patients I look after is about 83 they're all they're. They're pleased to be talking about it. You know, they want to have control over what happens to them, and they want to know their clinical state as well. You know, often they don't either realize that they're poorly or they know it, but no one's told them it. So, uh, there will be the There are the older patients who find these conversations very difficult. But in the majority, um, that it's actually, you know, depending on how you approach it, it's actually quite straightforward. But chaplaincy is brilliant. And yeah, any anyone you've got there who can help, I would definitely say use great, thank you very much. It's so good to hear from somebody who's been at the forefront of putting this in place that's been involved in having these conversations and has worked through a lot of the stuff that the rest of us are continuing to work through. We are going to move on to our next speaker John is going to come back at the end, so they'll be opportunities for more questions. And I've got some questions, additional questions to get to you, but we are going to move on to our next speaker.