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Home | Articles | Treatment Escalation | Realistic Conversations

Realistic Conversations

Last updated 30th July 2021

Overview

  1. These conversations can be difficult to initiate but are important and necessary. Communication at this time should focus on ascertaining concerns and information needs. Active listening and empathy are key.
  2. There are a number of suggested approaches, all broadly similar and intended to ensure that people are prepared for the conversation, that current understanding of the situation is fully appreciated and options for most appropriate treatment are explored. It is most important that the conversation is focused around what can and will be done.
  3. RED-MAP and DECIDE are acronyms for two of these approaches – see below. Whichever approach you favour, these mnemonics offer a useful aide-memoire to help plan and guide the conversation.
  4. CPR, when it is discussed, is therefore placed in a context of joint overall understanding of the situation and should come towards the end of the discussion when its appropriateness as an intervention should be much clearer.

RED-MAP

Ready             Can we talk about your health and care? What’s changed?
Expect             What do you know / want to ask / expect?
Diagnosis        We know… / we don’t know… Questions or worries?
Matters            What is important to you now and in future?
Actions            What can help … Options we have are… This does not work … / will not help you because …
Plan                 Let’s plan ahead for when / if …

A detailed poster giving more examples of this approach is included in the Appendix to this document.

DECIDE

Define             the decision we should be considering
Explain             the situation
Consider         all the available options
Invite               views, values, beliefs, what’s important
Decide             together, weighing up person’s priorities and preferences
Evaluate          the decision: review, check understanding, offer follow-up discussion

What is not Helpful

  1. Avoid language that can make people feel abandoned or deprived of treatment and care.
  2. Phrases like “There is nothing more we can do” or “we are withdrawing treatment” are neither helpful or true. There is always something that can be done – see Palliative care Guidance at End of Life guidelines.

Frequently Asked Questions and Comments

  1. I thought that the TEP was meant to be used only for patients who are terminally ill.
    No, the scope for using the TEP is wider. Any patient who has the potential to deteriorate and need out-of-hours treatment should have a TEP.  The TEP is not an end of life care plan.
  2. Should the TEP be used for everyone?
    Not necessarily. However, where there is a risk of deterioration, completion of a TEP is strongly advised.
    In some places, the TEP is used for all patients – most commonly in units looking after elderly people. You and your team should discuss whether “TEP for all” may have significant benefits in your area.
  3. What if I don’t have time to have a conversation with every patient (or their family) that is unstable or at the end of life?
    If you are pressed for time then be selective. Identify patients for whom the absence of a TEP puts them at risk of harm. Time spent on such conversations is an investment – apart from being best practice, it can prevent a bad death or the consequences of a poor relationship with a family that results in a stressful complaint.
  4. If the patient lacks capacity and a family member is not present, what should I do?
    Having a discussion with a family member / the person holding Welfare Power of Attorney is strongly recommended. But if the patient is clearly unstable and further escalation of treatment is felt likely to cause distress or suffering and not in the patient’s best interests, then the TEP should be completed with documentation of the reasons for going ahead in the patient’s notes. Lack of capacity is not a contra-indication to making an TEP.
  5. Is filling in an TEP to say “for full escalation” not a bit superfluous? After all, for full escalation is the default position anyway.
    It can be very helpful to on-call staff to know for sure that a patient is indeed for full escalation. If they arrive at a bedside in response to an increasing NEWS score, then knowing that full treatment escalation is already agreed provides a secure basis for emergency decision making. The greatest fans of the TEPs are junior clinicians and Hospital at Night team members.
  6. What about DNACPR?
    It is still often the case that DNACPR orders are completed without a TEP. Why? In fact cardio-respiratory arrest is uncommon. DNACPR in isolation is often insufficient. Knowing in advance whether or not it would be appropriate to undertake major interventions other than CPR e.g. transfer to HDU / ICU, is much more relevant. So the TEP is more practical – and it covers DNACPR anyway.
    Some concerns with DNACPR in isolation are:

    • It’s much more appropriate to focus on treatments and interventions that may help and which will be provided.
    • Having a conversation about one intervention, i.e. CPR, can be uncomfortable for patients / families if this is unexpected and can cause perplexity and distress.
    • It can lead to a perception in the minds of some that DNACPR is code for “do not treat”.
  7. Why are there different versions of the TEP?
    Following discussions with teams representing as many relevant areas as possible across the board area, we have now agreed to promote the generic TEP for all situations including COVID-19. The Beatson use the same TEP with minor wording changes reflecting their local arrangements.
  8. It’s a nice idea and I agree with the concept, and but does the TEP work?
    Yes. The evidence to support the use of the TEP concerns medical harms. In a Cambridge study, using the local version of the TEP achieved a reduction in treatment-related harms of nearly 40%. There is just as much ethical responsibility to avoid harm as there is to achieve good, especially in situations where the potential for harm outweighs the potential for good.
  9. Won’t making an TEP damage the doctor / patient relationship?
    This is an understandable concern, however there is no evidence to support this. On the contrary, many patients welcome the opportunity to discuss their prognosis but only a small minority take the initiative. The TEP conversation is the key to facilitating this. Patient’s hopes for their future and their priorities can be established at this point too.
  10. How can I find out more about TEP and related training?

Content by Dr Sarah Pickstock