Planning and decision making

Recommendation 1: All patients at risk of clinical deterioration should have a documented anticipatory care plan that is completed with input from the patient and their family. Documented plans should be accessible to all care providers.

Recommendation 2: The anticipatory care plan should include a decision on cardiopulmonary resuscitation in the event of cardiac or respiratory arrest.

Recommendation 3: Cardiopulmonary resuscitation status should not be the sole focus of the anticipatory care plan.

An anticipatory care plan (ACP) documents a care plan with recommendations to guide treatment and care decisions should a patient become acutely unwell at some point in the future. An ACP is often completed in an outpatient setting or at the point of hospital discharge. It will often include decisions about escalation to critical care, other interventions and hospital admission. An ACP will usually address decisions about cardiopulmonary resuscitation status. It may also define in what situations other treatment options such as palliative care may be considered. The ACP may also include preferred place of care, and statements of values (eg patient views on balancing extending life with maximising comfort and dignity, see section 8).

A feasibility study in a community setting came to no clear conclusions regarding outcomes after ACP intervention.⁵ A systematic review from 2014 dealt specifically with decision making in relation to DNACPR (do not attempt cardiopulmonary resuscitation).⁶ While some inference could be made regarding ACPs and treatment escalation plans (TEPs), it is not possible to draw firm conclusions.

The SIGN-endorsed guideline on shared decision making (NG197) from the National Institute for Health and Care Excellence (NICE) provides advice on how to support patients and families with decision making, which could help with creating ACPs or TEPs, as might Healthcare Improvement Scotland’s anticipatory care planning toolkit. The Chief Medical Officer for Scotland’s Realistic Medicine report (published 2022) endorses ReSPECT for emergency care planning.

Please refer to the Scottish Palliative Care Guidelines for further information. 

Recommendation 4: A treatment escalation plan should be formulated for patients at risk of clinical deterioration where the risks or benefits of certain therapies may be in doubt. The treatment escalation plan should be formulated with input from the patient and their family.

Recommendation 5: The treatment escalation plan should incorporate a decision about cardiopulmonary resuscitation in the event of cardiac or respiratory arrest.

Recommendation 6: Cardiopulmonary resuscitation status should not be the sole focus of the treatment escalation plan.

Recommendation 7: The treatment escalation plan should include a comment on the patient’s medically assessed suitability for advanced therapy should further deterioration occur.

Good practice point 1: Treatment escalation plans should be reviewed regularly if the patient’s clinical status is changing.

Treatment escalation plans (TEPs) define which interventions might benefit an individual when they present to acute care or if they deteriorate further during an episode of acute care. The TEP may be informed by a patient’s ACP but also address the fact that the patient has presented to acute care services, and therefore by definition their clinical status is in flux. The interventions addressed by a TEP should include levels of invasive care to be considered. This may include consideration of advanced therapy in critical care such as invasive ventilation or renal replacement therapy. The TEP should also include consideration of cardiopulmonary resuscitation status. It may also define when other treatment options, such as palliative care, may be of benefit.

A narrative review outlines the current evidence regarding clinical outcomes associated with the use of TEPs.⁷