Treatment escalation plans

Guidelines

1. General

• The TEP is a summary document designed to record and communicate medical decisions in relation to the GOALS OF TREATMENT.
• The provisions of the TEP may be applicable now, or may be put in place to inform treatment of the patient in the future, i.e. what may be appropriate if the patent deteriorates.
• Communication with the patient or, if they lack capacity, their relatives, regarding the provisions of the TEP is essential. If a discussion is not possible, a TEP should still be put in place if in the absence of a TEP the patient is at risk of deterioration and/or harms through overtreatment / undertreatment. There is an ethical obligation to take all necessary steps to avoid harming the patient.
• TEPs help to provide out-of-hours staff with appropriate guidance about managing the deteriorating patient. Moral distress occurs when this is not available. Completing a TEP is a service to other nurses and doctors as well as to the patient.

2. Who is a TEP for?

Ideally, a TEP should be used for all acute medical / surgical admissions. Even if the patient is “for full escalation”. It is helpful for this to be recorded.

TEPs are clearly indicated for patients whose condition is unstable, or who are at risk of deterioration, or are “sick enough to die”.

At the very least, TEPs should be used in patients characterised by:

• Severe frailty, or admitted from a nursing home.
• Progressive organ failure with / without co-morbidities.
• Progressive incurable disease e.g. dementia, MND.
• Cancer currently being treated – irrespective of the prognosis
• At request of patient / welfare attorney or guardian / nearest relative.
• To continue provisions of existing ACP / ReSPECT / Key Information Summary (eKIS) / Anticipatory Care Plan.

3. Practical guidelines

1. Lines of responsibility. The TEP process may be initiated by trainee doctors or senior charge nurses. It requires to be endorsed at the earliest opportunity by a more senior clinical team doctor (ST4 or above, or consultant). FY and trainee doctors should seek decision support in creating a TEP from senior colleagues. The consultant carries ultimate responsibility for the provisions of a TEP.

2. There should be no DNACPR without a TEP. This is a standard of care. A red DNACPR form should still be completed. The TEP form is not a replacement for the DNACPR form even although reference to CPR is made in the TEP.

3. Review process. The TEP should be reviewed and modified regularly, especially if the patient’s circumstances change over time, and hence the Goals of Treatment need to be changed.

4. The current TEP applies to the current admission only and cannot be carried forward to subsequent admissions.

5. Goals of treatment.  A brief summary should outline “what are we trying to achieve” and “what should be done of things get worse?” This should be written free-hand in the appropriate box.

Example: “End-stage cardiac disease. Relieve pulmonary oedema with diuretics + morphine, but no intervention in the event of further MI or arrhythmia. DNACPR. Aim to get home”.

Deciding on the Goals of Treatment means considering THE CONTEXT as well as the likely course of the illness.

Consider …

• If the patient has an illness trajectory such that they are likely to be in the last 12 months of life? (consider the Surprise Question).
• If the Clinical Frailty Score of ≥6 OR is the patient a nursing home resident.
• If the patient has advanced progressive disease: organ failure, neurological disease incl. dementia, cancer, multiple co-morbidities.
• The current status is characterised by refractory abnormal observations e.g. GCS<5, BP<60 systolic, SaO2<85% in which a diagnosis of “actively dying” has been confirmed and documented?

NB The presence of chronic stable disability should never be a priori the basis for treatment limitation.

Deciding on the Goals of Treatment means considering THE CONSEQUENCES of any intervention or escalation. The consequences are not necessarily short-term. They include futility and harms. Sometimes short-term gains lead to long-term consequences that are detrimental or frankly harmful or that the patient may not want.

Example: 34% of people discharged from Critical Care after mechanical ventilation have impaired cognitive function for 6 months or longer and as a result lose independent living. Long-term outcomes may influence whether the patient wishes treatment to be escalated or not.

Reversibility.The reason for admission may be pathological process that is in itself reversible. However, whether it is desirable to make the attempt needs to be carefully weighed up. For example, a patient with lung cancer may have hypercalcaemia or a bronchopneumonia, but the acute condition may be an end-of-life event. In this situation, palliative rather than “curative” interventions are much more appropriate. Treating a reversible process may be explicitly contrary the patient’ wishes.               

Occasionally, intervention may serve the patient’s wishes to “buy time” in the course of the dying process. For example, it may be legitimate to prescribe antibiotics to a patient dying of terminal bronchopneumonia in order that next of kin have time to arrive at the bedside. Sometimes the same intervention will prolong the dying process and add to a patient’s suffering.

6. Appropriate / Inappropriate interventions and treatments. The section on “Escalation Plan: interventions” is not a menu, but a prompt to consider whether some common interventions are really needed or are likely to be non-beneficial or even harmful. Harms often come from what seem like trivial procedures – but they are not trivial to the patient. This applies to all patients, and not just those who are terminally ll.

Palliative treatments may be needed immediately on admission. Palliative treatments should not be delayed and can be given along with, rather than as an alternative to, other interventions. Palliative treatment may be all that is appropriate in some circumstances.

Example: If palliative surgery (e.g. repair of #NOF) is being considered in a patient with Frailty Score ≥6 who has had a fracture, then a TEP to guide the management of potential post-op. complications is strongly advised such that post-op complications are treated palliatively where that is appropriate.

7. If Critical Care is to be considered, then early consultation with the Critical Care consultant is essential. Ideally whether or not the patient might require transfer to Critical Care in the event of significant future deterioration should be considered at the time of admission or during a ward round. Do not wait until the patient “crashes” or the Early Warning Score increases before making a referral. If in doubt, request an early consultation.

4. Discussion with patient and related issues

1. Discussion with the patient (or their family member) is an essential element in setting the goals of treatment and developing a TEP. Explaining the reasons for the illness and how co-existing conditions / the patient’s overall health status (e.g. high Frailty Score) will affects the choices that are available is the essence of the conversation.

2.  Decision-making capacity. You should consider whether the patient has mental capacity to be involved making decisions about their care. Patients who are physiologically unstable may not be in a position to fully consider the implications of their treatments. In acute illness, loss of decision-making capacity may be temporary and if so, future decision-making should involve the patient.

Refer to Adults with Incapacity (Scotland) Act (2000)). Complete an AWI Section 47 form if necessary.

3. Impairment of decision-making capacity does not preclude use of the TEP.

In all but exceptional circumstances, the goals of treatment are jointly agreed with the patient and/or family and/or legally appointed representative, and should be documented. However, if it is not possible to have the conversation, but it is clear that a particular intervention would be harmful now, or later if there is deterioration, or burdensome or contrary to patient’s known wishes (in eKIS or ACP), then a TEP should be put in place. The clinician’s ethical responsibility is to ensure that medical harms are avoided. A TEP should be put in place if there is a potential risk of significant harm by not having a TEP.

Discussion with a patient need not be long, but it does need to be truthful as well as empathetic. Initial questions can be based on the REDMAP questionnaire. (See: https://www.spict.org.uk/wp-content/uploads/2019/04/ACP-Talk_RED-MAP_April2019.pdf).  It can be helpful to engage patients in shared decision-making by outlining the “best case scenario” and the “worst case scenario” in relation to prognosis and possible outcomes and asking the patient for their opinion. (See: https://www.nejm.org/doi/full/10.1056/NEJMp1704149)

A brief record of the discussion and the patient’s and / or family member’s understanding should be entered into the patient’s notes. This need only be brief e.g. “Goals of treatment and what to do if things deteriorate was discussed with patient and he/she is in agreement.” It should be made clear on the TEP where this information is to be found (date of entry).

5. Medico-legal and ethics issues

1. The TEP is not legally binding in the same way that an advanced directive is. However, its provisions should be adhered to as far as possible, but there may be circumstances when it is wise to over-rule the provisions of a TEP. In any event the TEP should be reviewed and revised regularly during an admission and especially if circumstances change.

2. Withdrawal of treatment. The TEP does not provide for the withdrawal of any treatment. This requires separate discussion and documentation.

3. DNACPR.  The medico-legal requirements for a TEP are identical to those that apply to DNACPR. NHS Borders medical directors strongly recommend that a DNACPR order should not be completed without a TEP. Discussing DNACPR in isolation or prior to discussing other treatment choices is fraught with hazard.  A DNACPR without a TEP is associated with a 3-fold increase in patient harms.

4.Discussing major potentially life-saving interventions. Major interventions (e.g. surgery to repair AAA, laparotomy, CPR) need to be discussed with the patient / family if the intervention is designated in law to be potentially life-saving, even if the intervention is not going to be offered to the patient. If the treatment is in this category, but is considered futile or contra-indicated, and is not going to be offered, the reasons for not offering this intervention still need to be discussed. This is to comply with the Appeals Court ruling on the Tracey case (2014) and the Supreme Court ruling on the Montgomery case (2015)*.

*See: Montgomery and informed consent: where are we now? BMJ, 12 May 2017