Planning and communicating treatment decisions in a context of clinical uncertainty presents a key challenge. Increasing evidence supports the desirability of documenting a care-plan that addresses options about treatment escalation (Treatment Escalation Plan (TEP)) ensuring quality of healthcare for patients, in line with their wishes, prevention from distressing treatments and unnecessary harm as end of life approaches (Dalgaard et al., 2010, Carey et al., 2015, Obolensky et al., 2010, Gott et al., 2011, National Confidential Enquiry into Patient Outcome and Death, 2012, Fritz et al., 2013).Aims
To ascertain current procedures for recording treatment decisions in situations of clinical uncertainty. To identify and characterise key components of TEPs and understand the implications of these when incorporated into clinical practice.Method
A scoping exercise of all UK NHS adult acute Trusts. Telephone interviews were conducted to gain more indepth knowledge of processes and analysed using directed content analysis. Where a TEP was in use, content analysis was conducted to understand the structure and information required to complete them.Results
55/150 Trusts provided details of systems used. Of these 43 had experience of using a TEP, 29 of which had been formally evaluated. A further 6 were sourced through online searches. There was wide variation in the processes used. Forms consistently attended to seven key components: Resuscitation; Communication; ceilings of care; supportive care; capacity; transferability; colour/format.Conclusion
TEPs are valuable in ensuring patients’ dignity and comfort when faced with acute pathophysiological deterioration at end of life and have potential to minimise harm from unnecessary and/or unwanted investigations and treatment. However, inconsistency in availability and incorporation into practice has implications for quality and consistency of patient care.