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Treatment Escalation Plans
Last updated 2nd August 2021
This document is intended to inform clinicians of the purpose of Treatment Escalation Plans, how to complete them and the benefits of realistic conversations with a structured communication skills approach.
Purpose of Treatment Escalation Plans
- To help minimise harm due to over-treatment or under-treatment
- To help ensure continuity of care – especially for on-call staff out-of-hours
- To help ensure that the goals of treatment of the people we are looking after and their families are understood and respected
Treatment Escalation Plan Completion
- In all but exceptional circumstances (i.e. when it is not possible to discuss treatment but clear that a particular intervention would be futile, burdensome or contrary to patient’s known wishes), treatment plans are jointly agreed with patients and/or family and/or legally appointed representatives and documented in the record. The TEP form clearly captures and records this information.
- The TEP is normally guided by and the responsibility of the consultant responsible for the person’s care but, where appropriate, can be initiated by senior or trainee medical staff, Charge Nurses or Advanced Nurse practitioners.
- It is important to establish whether patients have mental capacity. Patients who are physiologically unstable and undergoing active stabilising treatment may not be in a position to fully consider the implications of such discussions
- Please refer to Palliative Care Register, or Key Information Summary (KIS) as there may be an existing Anticipatory Care Plan (ACP). Existing ACP’s should be respected and honoured, though their provisions may need to be updated.
- A standard DNACPR form should still be completed. At this time, we must also consider the risk to staff in relation to droplet / aerosol formation and COVID transmission. The TEP form is not a replacement for the DNACPR even although reference to CPR is included in the document.
- The intervention options list is not a “menu” but a prompt. ITU referral must be preceded by a consultation with a senior clinician. Careful consideration should be given to other interventions or procedures that may be either appropriate or inappropriate.
- The relevant consultant / senior clinician must review and sign the plan within 24 hours of its completion. He / she carries ultimate responsibility for its provisions.
- The plan should be reviewed regularly during an admission. It can be amended but if multiple amendments are being made – replace the existing one with an updated fresh one.
- Where full explanations of discussions or decisions are documented in the record, the TEP should be annotated in the comments section to cross reference with that date in the record.
Health Records Guidance
- The TEP only applies to the current admission. At the time of any subsequent admission a new TEP should be completed. Any old Plan should have OBSOLETE written across it in block capitals with date and initials.
- Although it is recognised that there are minor variations in practice between wards, the TEP should be placed prominently within the patient’s hard copy hospital records, generally at the front of the at the front of the clinical notes, along with any DNACPR document if completed.
- On discharge the TEP must be scanned with the in-patient record (in the same way as a documented medical note of a discussion). This is to underline the point that the TEP only applies to that admission and while it may inform an ACP it is not an ACP
Ethics and Medico-Legal Issues
- The TEP is not a binding advanced directive.
- The TEP does not provide for the withdrawal of any treatment.
- The medico-legal requirements for TEP are identical to those that apply to DNACPR
Content by Dr Sarah Pickstock