25 January 2016
Having conversations about the best course of action in the event a person’s condition deteriorates is difficult for everyone involved, whether it is the patient themselves, their family or carer and the clinician.
After an initial study on Advance Care Planning (A. Richardson, S. Lund1), research into the current application of treatment escalation plans across the country, and early engagement with some of the acute trusts in the Wessex region, it was apparent there was a desire to improve this process.
A report recently published on the effectiveness of current processes, including the use of Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) orders2 suggested it was time to expand the use of the DNACPR form to incorporate detail on treatment decisions, linking DNACPR decisions to discussions about overall treatment plans.
The Treatment Escalation Plan (TEP) Project, the signature project for CLAHRC Theme 6 (Complexity and End of Life Care) started its journey in late spring of 2015; it focussed on acute hospital trusts, with a plan to develop a Wessex prototype and support roll out across the region, and extend to other settings in the longer term.
Working groups were initially set up with Salisbury, University Hospital Southampton and Hampshire Hospitals. Since then, the scope has widened to engage others in primary care, namely Macmillan GPs, a local GP surgery and a regional care home provider which has added further complexity, but also brought in a wide range of useful perspectives on this process.
As the project has developed, there has been a subtle shift in the objective and scope of the project, partly in response to the complexity we encountered on the ground in the Wessex region, and in particular once it became clear that a national initiative was underway to look at this issue for the whole of the UK.
The national working group, co-chaired by the Resuscitation Council (UK) and the Royal College of Nursing was entitled ‘Emergency Care and CPR Decision Making’; Professor Alison Richardson, who is leading on the service delivery aspects of the TEP project, was invited to join this working group in the summer of 2015.
What has now emerged from the working group is a set of proposals set out in the Emergency Care and Treatment Plan consultation which invites detailed comment on a series of documents (the ECTP form, guidance and information for all parties) by 0900 on Monday 29th February 2016.
As part of the collaborative nature of the CLAHRC project, we have engaged over 100 health professionals in the Wessex region who have an interest in this area, and communicated regular updates on both our own project and the national initiative. Being part of the national working group means that we are directly contributing to the co-production of a national document, policy about its conditions of use, and evaluation of its implementation.
In summary, the main aim of the CLAHRC project as a result of these changes is to develop a set of tools and resources to support patients, carers and professionals as they experience and respond to clinical deterioration at home, in the community or in hospital.
We want to improve communication and decision making around anticipated action at times of acute clinical deterioration. These tools and resources will comprise:
A workable Emergency Care and Treatment Plan (ECTP), either local or nationally produced;
A clear account of barriers and facilitators to ECTP implementation;
A generic implementation plan.
Looking ahead over the next few months, we anticipate a significant level of activity in terms of engaging our existing working groups in responding to the national proposals and testing these out in practice. Early testing has just begun, which will then be evaluated and inform decisions around implementation by each organisation involved. We will provide support where practicable in terms of toolkits, signposting to education and training, project management tools and advice. The project has evolved in response to local and national engagement and collaboration, very much in the spirit of the CLAHRC.
Original summary of TEP Project March 2015
1.Lund, S., A. Richardson, and C. May, Barriers to advance care planning at end of life: an explanatory systematic review of implementation studies. Plos One, 2014.
2. http://www.nets.nihr.ac.uk/projects/hsdr/12500155 and papers published from this
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