A Treatment Escalation Plan (TEP) is a communication tool which is helpful in hospital when a person with serious illness has the potential for acute deterioration or may be coming towards the end of their life. Sometimes doing everything possible may actually lead to harm – to more suffering and distress rather than less - and without any particular gain. What can be done and what should be done may not necessarily be the same thing. Treatment Escalation Plans should be discussed and made based on personalised realistic goals rather than ‘one size fits all’ treatment.
Crucially, a TEP provides on-call hospital staff with immediately accessible guidance about how to respond to an individual in times of crisis, especially out of hours and at weekends. A TEP becomes particularly important when there is agreement that interventions or referrals for more intensive care that are contrary to a person’s wishes or are futile or burdensome should not be undertaken. Equally in many patients who may have an agreed DNACPR, a TEP clarifies all the treatments and care that should continue.
The TEP being used in NHSGGC has recently been updated (Oct 2020) and is accessible via the following link:
Copies for your department can be ordered from GRI Medical Illustration ([email protected] or 0141 211 (2) 4692) quoting order number mi-314118.
In severe illness quality of care becomes more important than ever but the goals of treatment are different for different people. Hospital care is becoming more and more complex and both patients and their families are particularly vulnerable to the impact of errors, harms and poor communication. It is especially important for hospital staff to understand and respect the values and preferences of the people they are looking after and to discuss with them a plan for emergencies.
Knowing how the plans should be sensitively discussed and used is important and this link provides a framework for the discussion and further information for staff about on TEP completion and filing in the records.
TEP Guidance (DOCX)
Further advice to support staff planning conversations with people and their carers is included here, including demonstration videos and further information about the REDMAP framework.
Realistic Conversations – discussing Treatment Escalation plans – part 1: https://www.youtube.com/watch?v=PCo6jmZZm_k
Realistic Conversations Part 2: https://www.youtube.com/watch?v=164EsZmjW3M
The Difficult Conversations infographic and short explanatory video from NHSGGC’s Dr Lara Mitchell are excellent:
Of course, what is right at one moment may change over time. Treatment decisions and the TEP may need to be modified in the light of changing circumstances and possible changes in peoples’ wishes, so that interventions remain realistic and appropriate. This information leaflet encourages people in hospital to ask questions about their care.
It will shortly be available to be ordered from Medical Illustration and order details will be posted here.
To avoid any confusion or ambiguity, a TEP is not the same as an Anticipatory Care Plan (ACP). ACPs are normally held by patients (and increasingly can also be found in summary format on the Clinical Portal (filed under ‘preferences’.) The TEP relates only to the current hospital admission. It should reflect existing Anticipatory Care Plans and on discharge if anything has changed, should inform a new Anticipatory care plan.
Other important resources:
This NES TURAS module explores Shared Decision Making and the DECIDE model:
Scottish Palliative Care Guidelines are here and contain a range of resources: