Hello, my name's Robin Taylor, I'm a consultant respiratory physician working for
both NHS Lanarkshire and NHS Lothian in Scotland.
The topic for our thoughts is medical decision-making in acute care.
This is part 2 of a two-part presentation.
In part 2 I'm going to devote myself to discussing the rationale, and some of
the practical aspects of using treatment escalation and limitation plans.
I'm going to talk a bit about the moral distress that staff
encounter, in the context of medical decision-making,
particularly if that medical decision-making is inappropriate.
In part 1 I showed you this slide, and I'm not going to go through it in detail,
but I'm going to remind you that the background to devising
a treatment escalation plan has to do with
the context of the patient's illness, and the consequences of a patient's illness.
In a treatment escalation plan, we're going to consider (for a patient being admitted to hospital):
what are we going to do, or what are on-call staff going to be given guidance to do,
if the patient deteriorates further from how they are at the present moment?
The context I've already dealt with, in terms of Gold Standards Framework and Clinical Frailty Score,
the consequences are to think of the longer-term outcomes of intervention, as well as the immediate outcomes.
In the setting where I've been working, in NHS Lanarkshire,
we introduced TEPs about five years ago.
They have relevance both in the emergency department, and also in the acute medical and surgical wards.
At the time of admission, here are some of the things that need to be woven into
medical decision-making, and writing up or creating a TEP.
I've already mentioned the context.
You may be interested to know that we did a survey in
our hospital, of patients in acute medical wards,
using the Gold Standards Framework criteria,
which is to try to estimate how many patients are likely to be in the last 12 months of life.
Using this criteria in our acute medical wards,
in our hospital, 45 percent were within that category.
I've mentioned reversibility, is what we're dealing with reversible or irreversible?
That should be a conscious thought.
The default response is to assume that everything is reversible,
but sometimes it isn't, and we should avoid
the indulgence in what I called previously 'last chance medicine'.
Because that, if you don't mind me saying so, is a cop-out to making the right choices.
We have to consider that the interventions may be non-beneficial, and
some interventions in themselves are quite arduous for patients to experience,
operating surgically, non-invasive ventilation even.
Some patients have had the experience and they don't want it again.
There are the consequences in the longer term, of going to ICU, or going to surgery.
We've got context and consequences.
In that regard a treatment escalation plan communicates about
the current and future interventions, that may or
may not be consistent with the agreed goals of treatment.