Treatment decisions in the face of patient deterioration in hospital: development and implementation of treatment escalation plans (TEPs)
People whose health is deteriorating can find their ability to say what care they want difficult. Sometimes patients and their families experience heroic but distressing efforts to ensure survival in which physical comfort and personal dignity become difficult to maintain.
Currently very few people (4%) discuss what type of care they would or would not like in an emergency situation. For patients, families and healthcare professionals deciding on the best thing to do can be very hard.
Researchers at the University of Southampton are working with NHS partners to develop, implement and evaluate a tool known as a Treatment Escalation Plan (TEP); this aims to help patients, their families and healthcare professionals talk about treatment decisions that have to be made when a person is seriously unwell and their health is at risk of deterioration.
TEPs are developed by the most senior medical clinician looking after the patient in discussion with the patient and family and helps set out what care the medical team feel is appropriate if a patient deteriorates and allows it to be clearly recorded. They can be used to discuss with patients and their next of kin what course of action clinicians think would or would not be appropriate and set limits on medical treatment for those who are very unwell and/or in the event they might deteriorate. They are about judging what could be done and on occasion what should not be done, for example whether to start a new course of antibiotics, put someone on a ventilator or perform dialysis. It also usually includes an indication of whether someone should be transferred to intensive care.
TEPs have the potential to provide clarity of instruction in the event of deterioration and will improve how these types of decisions are approached, discussed and communicated, making conversations between patients, those close to them, and health professionals easier. They provide a way in which these decisions can be documented and shared with other health professionals involved in looking after the patient.
The project encompasses a range of activities: audit, service development, research and evaluation and includes the following activities:
- Extract, analyse and evaluate patient data from one acute trust to understand clinical decision making at end of life, to track the impact of TEP implementation and enable improved quality of care at end of life.
- Working with groups of healthcare professionals to understand what a TEP should include, both the form and process.
- Identify what forms work best for each setting.
- Engage patients, carers and the public to find out what is important to them in this process.
- Support cycles of testing of the TEP process in a range of settings and evaluate to understand what works.
- Support organisations to implement TEP through toolkits, project management advice and signposting to educational resources and training materials.
Research and Evaluation:
- Understand enablers and barriers to implementation of TEP.
- Evaluate implementation in a series of organisations to understand how this process is adopted in different ways, how individuals and specialisms engage differently and how acute varies from primary care.
We aim to develop a set of resources to support patients, carers and professionals as they experience and respond to clinical deterioration at home, in the community or in hospital.
• A workable Treatment Escalation Plan,
• A clear account of barriers and facilitators to implementation;
• A generic implementation plan.