Treatment escalation plans

Introduction

Shared Decision-Making (SDM) is increasingly expected in most aspects of UK medical practice and can be particularly important for older patients to guide goals of care. Treatment Escalation Plans (TEP) summarise medical intervention to be attempted in the event of acute deterioration. Current guidance advocates SDM in TEP but it is unclear whether this is considered practicable by clinicians. This study aims to understand clinicians’ perspectives on SDM in TEP for older patients in the acute medical setting.  

Methods

This was a qualitative study following a relativist constructivist approach. 26 consultant and registrar doctors were recruited from general internal medicine, intensive care, palliative care and emergency medicine. A clinical doctoral student conducted semi-structured interviews including vignettes of older multi-morbid patients with capacity to discuss treatment escalation. Reflexive thematic analysis was performed. Ethics approvals were obtained from the Health Research Authority 22/HRA/4387.

Results

Three themes were generated: ‘An unequal partnership’, ‘Options without equipoise’ and ‘Decisions with shared understanding’. SDM incorporating patient preferences with clinical opinion was seldom perceived to be appropriate. Clinical complexity and use of intuition, together with lack of perceived moral equipoise, motivated clinicians to develop medically acceptable TEPs. Shared understanding with the patient and family and avoiding conflict were important.

Conclusions

Contrary to current guidance, SDM was considered a potential barrier to formulating appropriate TEPs in the acute medical setting. This study suggests potential incompatibility between policies prioritising patient autonomy and the right to make unwise decisions, and those stating clinicians’ prerogative to determine realistic chance of treatment success and not provide intervention considered medically inappropriate.  

Background:

Clear and accurate documentation of a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision is vital to ensure patients receive appropriate care and autonomy regarding their end-of-life management. Inaccuracies or omissions allow potential for unnecessary or harmful interventions to occur.

Aims/Objectives:

To produce ≥20% improvement in accuracy and overall completion of all sections of respiratory inpatient ReSPECT forms, with particular focus on DNACPR decisions, during a four-month respiratory placement. 

Methods:

Between 21/12/21-29/4/22, DRI inpatient ReSPECT forms were reviewed for completion and accuracy overall and for individual subsections. After two weeks’ pre-intervention data collection, three interventions with complete PDSA cycles (junior presentation, ward posters and emailed consultant presentation) were implemented over 11 data collection points. Interventions reminded doctors to review forms and identify/rectify errors.

Results:

Name documentation showed a 5% sustained improvement. Consultant countersignature completion improved from baseline over seven consecutive data timepoints but wasn’t sustained long-term. No intervention significantly improved overall form completeness and patient preferences remained poorly completed (all ≤30%). 100% documentation of DNACPR status at baseline was sustained throughout. However, discussion details remained poorly documented without significant improvements seen.

Conclusions:

Despite some minor improvements seen, no intervention produced sustained changes to overall completion or key sub-sections. Sample size and project duration are recognized limitations. However, these null results emphasize that current forms are not utilized as intended and that ReSPECT completion could be significantly improved. Findings have contributed to wider research by Palliative and Resuscitation teams.

The 2020-21 Chief Medical Officer report described Treatment Escalation Plans (TEPs) as ‘Realistic Medicine in action.’ Our aim is to increase TEP completion on the Medicine of the Elderly (MOE) wards at the Royal Infirmary of Edinburgh to >90% by July 2023.

Since August 2022, we collected weekly data from a single MOE ward. In October, we upscaled to include four MOE and one stroke ward. The notes of five randomly selected patients were reviewed weekly to see whether they have a TEP, and if so, which parts were completed. To further understand behaviours around TEP completion, we collected qualitative data asking doctors what the triggers and barriers were to TEP completion. 40% found the conversations challenging whereas 30% cited time and environment as barriers. We used this data to generate change ideas. For PDSA cycle 1, we developed a teaching session around TEP conversations. This is delivered regularly to all junior doctors and ANPs in the department. For PDSA 2, we allocated a weekly ward ‘TEP champion’ to highlight patients without a TEP and encourage completion.

Median for TEP completion was 75% on the initial ward, 42% over the four MOE wards and 20% for the stroke ward. All patients with a TEP had their resuscitation status documented. One third of patients did not have a TEP at all. Of the two thirds of patients with a TEP, a quarter were incomplete. Sections on goals of care, communication and interventions were completed in around half.

This project is ongoing with future PDSAs planned to address the barriers of time and environment. PDSA 3 will test the introduction of a mobile TEP phone to enable discussions in a quieter environment. The variation in practice in MOE versus stroke is important and requires further understanding of the barriers specific to stroke.