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A patient and relative centred evaluation of treatment escalation plans: a replacement for the do-not-resuscitate process
  1. L Obolensky,
  2. T Clark,
  3. G Matthew,
  4. M Mercer
  1. Departments of Anaesthesia and Critical Care Medicine, and Orthopaedic Surgery, Torbay Hospital, Torquay, Devon, UK
  1. Correspondence to Lucy Obolensky, Derriford Hospital, Plymouth, The Great Hall, Combefishcare, Ipplepen, Devon TQ12 5UQ, UK; lucyobolensky{at}live.co.uk

Abstract

The Treatment Escalation Plan (TEP) was introduced into our trust in an attempt to improve patient involvement and experience of their treatment in hospital and to embrace and clarify a wider remit of treatment options than the Do Not Resuscitate (DNR) order currently offers. Our experience suggests that the patient and family are rarely engaged in DNR discussions. This is acutely relevant considering that the Mental Capacity Act (MCA) now obliges these discussions to take place. The TEP is a form that the doctor completes, ideally with the competent patient or close relative, documenting what treatment options would be appropriate if that patient were to become acutely unwell. Ventilation of the lungs, cardiac resuscitation, renal replacement therapy, intravenous fluids and antibiotics are all discussed. The study evaluated patient and relative experiences with the TEP. 55 patients or their relatives were interviewed regarding their experience of the TEP and thoughts regarding the process. 96% of patients and relatives evaluated thought that the TEP was a good idea. Free text comments were all positive and only 34% of patients claimed to feel anxious when completing the form. Following this study, the TEP has been expanded hospital wide and into the community within our trust. Discussions are currently taking place in hospitals within our region to introduce the TEP form into other local trusts.

  • Attitudes toward death
  • care of the dying patient
  • prolongation of life and euthanasia
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The first description of external cardiac massage was in 1960.1 A corollary of this is that there will be patients for whom this process may be considered inappropriate, for example the dying and in some circumstances the terminally ill. In 1974, the American Medical Association proposed that decisions not to resuscitate should be entered into the medical notes and communicated to all attending clinical staff.2 In 1976, two North American centres were the first to describe their process of deciding that a patient should be the object of a do-not-resuscitate (DNR) order.3 4

Later, various authors commented on the variability in the way in which DNR orders were interpreted and the differences in care that this might mean for the patient. This led to the concept of more specific individualised patient plans that detailed which treatments were and were not appropriate.5–7 The introduction of such plans led to improved communication and documentation of the individualised patient treatment plan.8 9

It is our opinion that the DNR process has additional serious problems. It is a negative concept to discuss with vulnerable patients and relatives. It misses an opportunity to discuss with the patient and family a broader plan of care.10 Such discussions can lead into a more positive conversation outlining all those treatment actions that will be undertaken and which will then lead to agreement on what other treatment options, not just CPR, would be inappropriate. Clearly, without these discussions, the patient may be the subject of a treatment modality that they would not want, for example invasive ventilation of the lungs for acute respiratory failure. Conversely, without these discussions, the patient may not be the subject of a treatment modality that they would want. Patients' thoughts governing their DNR order may not necessarily support non-treatment of other life-threatening states, and although many DNR policies consider DNR orders as fully compatible with aggressive care, they may actually lead to less intensive care.11

Moreover, our experience suggests that the patient and family are rarely actually engaged in the DNR discussions. A recent audit of junior doctors' experiences of DNR forms in our hospital (unpublished work) showed that more than two thirds were completed without discussion with the patient, and more than half without discussion with the relatives. This is acutely relevant, considering that the Mental Capacity Act (MCA)12 now obliges these discussions to take place.

In an attempt to improve patient and relative involvement and experience, and to embrace and clarify a wider remit of treatment options, since 2006, we have introduced the Treatment Escalation Plan (TEP).13 This a form (appendix 1) that the doctor completes—in discussion with the competent patient or relative—documenting what treatment options would be appropriate if that patient were to become acutely unwell. The patients that are chosen are those that the individual clinician deems are at risk of clinical deterioration. Ventilation of the lungs (invasive and non-invasive), cardiac resuscitation, renal replacement therapy, intravenous fluids and antibiotics, among others, are discussed. The form is easily identifiable and filed in the patient's clinical notes.

Initial local evaluation of our medical and nursing staff has been positive.13 Initial patients' and relatives' experiences of TEPs have been similar.14 Here, we present further findings of a patient and relative centred evaluation of the TEP process.

Methods

This study was classified as a prospective quantitative and qualitative evaluation of an existing service and, as such, did not necessitate ethical approval.

The study was based on two acute orthopaedic and trauma wards in a district general hospital, and was undertaken throughout early 2008. All of the clinical investigators had prior experience of using the TEP form.

One of the investigators (GM) was responsible for taking the patients and relatives through the TEP process. Patients were chosen at the discretion of the investigator on a clinical basis—being that it was felt that the patient was at risk of suffering a clinical deterioration (eg, due to old age, immobility, comorbid conditions, complexity of surgery). Fifty-five patients or their relatives were approached. This investigator visited the patient and first assessed their competence in line with MCA guidance. If the patients were competent, they were interviewed; if not, their next of kin or another close relative was interviewed. All interviewees were first asked for their verbal consent. One patient refused to engage with the TEP process. The interview first explained the TEP process and then sought answers to the questions on the TEP Form (appendix 1). The TEP form was then filed in the patients' clinical notes and used as a guide for their plan of care.

Two of the investigators (MM, TC) were responsible for the evaluation of the TEP process. Between 24 and 72 h after the initial TEP interview, the competent patients or their relatives were again interviewed either face-to-face or through a telephone conversation. The interviewer explained the nature of the evaluation and ascertained verbal consent to continue. All patients and relatives (n=54) approached for the evaluation of their TEP gave verbal consent to be interviewed.

Answers were sought to questions on the TEP Evaluation proforma (appendix 2). For the purposes of this study, only quantitative results to questions 2a and 5, and qualitative results (freetext answers) to question 2b, were analysed.

All patients or their relatives enrolled were in a pre- or post- operative period. Also, it was noted if patients and relatives either did not understand the process (Question 1b) or did not remember it happening, or both (table 1).

Table 1

Patient and relative demographics

A limited validation of the TEP Evaluation proforma (appendix 2) was also undertaken. The two investigators (MM, TC) responsible for the evaluation of the TEP process both independently evaluated the same five patients and three relatives. The evaluations were then compared.

Results

There was no statistically significant difference between the reporting of anxiety between patients and relatives (χ2 test) (table 2).

  • In total

  • Pre-operatively

  • Post-operatively

Table 2

Patient and relative questionnaire responses

There was no statistically significant difference between reporting of anxiety pre-operatively and post-operatively for (Fisher's Exact test) (table 3).

  • Patients and relatives in total

  • Patients

  • Relatives

Table 3

Patient and relative responses for anxiety by operative status

Representative freetext comments were collated as follows:

Q2b. How did undertaking the TEP process make you feel?

  • Thankful that these treatments exist.

  • I felt that it was a good thing to know about these treatments and things.

  • Made me feel looked after.

  • I was reassured.

  • Caused me to face reality and put things into perspective.

For the answers obtained by two investigators (MM, TC) using the TEP evaluation proforma (appendix 2) independently on the same eight patients/relatives, agreement was 100% (eight out of eight) on questions 1b and 5, and 87.5% (seven out of eight) on question 2a.

Discussion

Patients think that the TEP is a good idea

The General Medical Council is currently consulting on its new draft guidance for end-of-life care.15 It acknowledges that the most difficult and sensitive decisions in end-of-life care are often those around starting, or stopping, potentially life-prolonging treatments such as CPR. In a recent British Medical Journal article,16 Sokol highlights problems with the DNR process, including the public's over expectation of the success of CPR and the difficulties of medical staff undertaking “awkward” conversations with patients around this issue. As an alternative to DNR, a different approach is discussed; Allow Natural Death (AND) as a way of broadening the remit of the discussions beyond CPR to involve other treatments such as ventilation of the lungs, dialysis and antibiotics. Making such advance plans puts the patient back at the centre of their care. The importance of such an approach is recognised in the Royal College of Physicians 2009 guide to Advance care planning,17 which states“At the core of current health and social care are efforts to promote patient-centred care, offer choice and the right to consent to or refuse treatment and care offered…Advance care planning may help…”.

It is our view that the DNR process has run its course and that a broader process such as TEP should replace it. The NHS End of Life Care Strategy stipulates that all people approaching the end of life need to have their needs assessed, their wishes and preferences discussed and an agreed set of actions reflecting the choices they make about their care recorded in a care plan.18 The DNR remit is clearly too narrow for this, while a TEP will fulfil its requirements. Locally, we have compared the DNR and TEP process.19 Of 30 patients evaluated, 26 would rather complete the TEP process if required, as opposed to four for the DNR process.

We have highlighted problems with the DNR process earlier in this article. There is often poor communication with patients and relatives when deciding the DNR orders. However, the MCA states that, for every serious medical treatment, we must seek the patient's or relatives' agreement.4 We see communication as pivotal when completing the TEP process, ensuring the patient's legal and ethical right to autonomy is upheld.

Is undertaking the TEP process time consuming, or more time consuming than undertaking the DNR process? It probably is, but the technique of advanced planning will certainly prevent patients receiving (time-consuming) interventions that they may not have wanted.20 We suggest that a little “up front” investment of time is in the patients' best interests, as well as ultimately being time saving for attending clinicians. Moreover, evidence is lacking that advance planning leads to the denial of appropriate healthcare.21

As well as in the acute Trust setting, we now see a role for the TEP process in community hospitals. We are now piloting this. General practitioners (GPs) are able to formalise a plan of care for the patient at risk of deteriorating. Communication with out-of-hours staff will then be seamless and reflect the patients' best interests and uphold their autonomy. A particularly relevant question whose answer is documented is “Is this patient for transfer to an acute trust—yes/no?”

It would be similarly possible to have such care plans residing with patients in their homes. These could be ready reference for all attending staff, including GPs and ambulance crews, to guide their response to an acute situation.

Medical staff undertaking TEP discussions must have adequate communication skills and knowledge. They should not hesitate to defer to other colleagues if their skill set is being exceded.17

Is the TEP evaluation proforma (appendix 2) valid? We only attempted to evaluate this tool in a small number of patients and relatives. In this context, it achieved a good level of agreement between investigators.

Our results show that 96% of patients and relatives think that the TEP process is a good idea, and only 34% were made anxious by undertaking it. We think that the freetext comments are insightful and positive.

The DNR process is a negative approach to a plan of care and misses the opportunity to clarify the patient's approach to other potential treatments. We doubt if the current approach to DNR is now legal, and we advocate improved communication with patients and relatives to involve them in decision making.

In conclusion, we will continue to embed this process in our trust in an attempt to ensure that patients are not the potential subject of inappropriate interventions and that their autonomy is respected.

References

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Supplementary materials

Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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