Background Ceiling of Treatment (CofT) is a protocol designed to:
Encourage prognostic conversations and planning for treatment limitation/escalation in the event of acute deterioration in hospital patients nearing end-of-life.
Facilitate improved out-of-hours communication and reduce discontinuity of care.
Minimise interventions that are futile, burdensome, or contrary to the patient’s wishes.
Prompt palliation of acute symptoms irrespective of cause.
Six condition-specific formats have been introduced across 3 hospitals.
#1. to assess effectiveness as judged by hospital staff (n = 18);
#2. to explore relevance in patients attended by hospital Rapid Response Team (RRT) (n = 85) AND with DNACPR order (n = 9);
#3. to quantify CofT use among palliative care (PC) referrals (n = 28).
Methods Three audits. (#1) A questionnaire was administered to ward staff. (#2) Detailed case review was undertaken. (#3) Frequency of use was documented.
Results (#1) 17/18 (93%) reported that CofT had a positive impact on patient care. (#2) 8/9 RRT-attended crises were allegedly “reversible”; 3/9 had CofT; in 6/9, if the treatment plan had been written prospectively using CofT, inappropriate interventions would have been avoided in 6/9. (#3) CofT was documented in 10/26 (38%) of PC referrals but deemed appropriate in 26/28 (93%).
Conclusions (#1) CofT provides for more secure decision making among hospital staff dealing with acute crises in end-of-life patients. (#2) Lapses in communication rather than failure to consider limitations of treatment result in over-treatment. CofT would be beneficial. (#3) All patients referred for palliative care would benefit from CofT in addition to DNACPR.
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