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P-29 Has a global pandemic helped doctors talk about ceilings of care, and can we keep it going? Looking at medical admissions in a District General Hospital as it recovered from the first wave
  1. Nicola Williams
  1. Worcestershire Acute Hospitals Trust


Background Admission to hospital is associated with significant mortality.1 Admission should prompt early consideration of ceilings of care (CoC) to ensure appropriate treatment provision. Delays in these decisions can lead to care mismatched with patient wishes, inappropriate escalation, delays in palliation, less time to come to terms with prognosis for patient and loved ones, as well as difficulties for staff out of hours. The post-take ward round (PTWR) often represents the most appropriate time to discuss CoC, as comprehensive patient information and consultant support are available. During the first wave of the Covid-19 pandemic, emphasis was put on early decision making and communication of CoC.2

Aim To ascertain if one month after first lockdown, as the hospital was recovering and normalising, whether early decision-making regarding ceilings of care continued.

Method PTWR proformas and Respect forms for 50 medical patients admitted to Alexandra Hospital Redditch during February 2020 were audited for CoC documentation. Due to the covid-19 pandemic, the UK went into lockdown from March to July 2020. Over one month later, in August 2020, a second audit of 50 patients was completed

Results From pre-covid to one month after lockdown was lifted, CoC documentation at PTWR increased from 4% to 18%. For patients aged over 70, documentation increased from 6% to 23%.

Discussion Results were likely heavily influenced by the unprecedented covid-19 pandemic. These results are likely due to more pro-active clinical decision making as a result of the acute crisis, awareness of bed pressures and a shift in perception of the importance of CoC. Potential alternative reasons include raised public awareness prompting patient-led discussions, or increased openness to care planning. Despite this, there is still room for further improvement in discussion and documentation of CoC as we continue to rebound from this crisis.


  1. Moore E, Munoz-Arroyo R, Schofield L, et al. Death within 1 year among emergency medical admissions to Scottish hospitals: incident cohort study. BMJ Open 2018;8:e021432. doi: 10.1136/bmjopen-2017–021432

  2. Coleman JJ, Botkai A, Marson EJ, Evison F, Atia J, Wang J, Gallier S, Speakman J, Pankhurst T. Bringing into focus treatment limitation and DNACPR decisions: how COVID-19 has changed practice. Resuscitation 2020 Oct;155:172–179. doi: 10.1016/j.resuscitation.2020.08.006. Epub 2020 Aug 20. PMID: 32827587; PMCID: PMC7438269.

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