Background The number of patients dying in hospital continues to remain high. One of the challenges in combating this is deciding when to actively manage a patient and when to withhold/withdraw treatment. Advance Care Planning concentrates on patient-driven decisions, planning ahead in case they lose capacity to make decisions. Less attention has focused on clinician-led decisions, especially anticipating problems and planning for clinical deteriorations. Treatment escalation planning is one mechanism of planning the care of a patient at risk of deteriorating.
Method Treatment escalation planning was introduced as a pilot in the following settings in a general hospital: Respiratory, Cardiology, Care of the Older, Medical Assessment Unit/General Medicine, Critical Care and Palliative Care. Audits were carried out in each setting, looking at decision making, before and after the pilot were carried out. The outcomes were measured and feedback obtained from staff in relation to ease of use, issues encountered and practicalities.
Results The use of Treatment Escalation Plans was popular with junior doctors, especially out of hours. Advantages of using the plans included: creating a culture of thinking ahead, a simple format, and in a few cases patient decisions were affected by the plans. Disadvantages were that most patients during their admission did not need the plans created; the decision making and communication of decisions took extra time.
Conclusion Treatment Escalation Planning is a potentially powerful tool in trying to deliver appropriate levels of patient treatment. Dilemmas arising from this study include whether to implement this process for all patients (most will not benefit) or for a selected group (at present the authors are not good at predicting patients who will deteriorate acutely). In addition, it raised a number of ethical questions around the communication of decision making, and the level of patient involvement in clinical decision making.
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