Background Ceiling of Treatment (CofT) is a protocol designed to:

1. Encourage prognostic conversations and planning for treatment limitation/escalation in the event of acute deterioration in hospital patients nearing end-of-life.

2. Facilitate improved out-of-hours communication and reduce discontinuity of care.

3. Minimise interventions that are futile, burdensome, or contrary to the patient’s wishes.

4. Prompt palliation of acute symptoms irrespective of cause.

Six condition-specific formats have been introduced across 3 hospitals.

Aims

• #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.