A ‘smorgasbord’ of options? How do clinicians make Treatment Escalation Plans with older patients in hospital?

Dr. Bronwen Warner is a medical registrar based in London and is currently undertaking her PhD at Imperial College London. Her research explores Shared Decision-Making in Treatment Escalation Planning for older patients in the acute medical setting. In this BGS blog, she talks about a study recently published in Age and Ageing: Shared decision-making with older people on TReatment Escalation planning for Acute deterioration in the emergency Medical Setting: a qualitative study of Clinicians’ perspectives (STREAMS-C)

Have you ever had a Treatment Escalation Planning or cardiopulmonary resuscitation conversation with a patient and found yourself saying, “Well actually, this is a medical decision”? And if so, were you right?

Treatment Escalation Plans are a ‘what do we do if…?’ contingency for how invasively to treat a patient if they become very unwell, balancing the benefits and harms. Treatment Escalation Plans cover interventions such as organ support on the intensive care unit and cardiopulmonary resuscitation. They are often made when an older patient first arrives in hospital as an unplanned medical admission.

It feels unusual nowadays to read a clinical guideline and not see the words ‘Shared Decision-Making’. This term means patients and clinicians coming together to agree a management plan. The idea that patients should be influential in decisions about their health is increasingly expected in western medicine, reflecting a move in wider society towards greater individual autonomy. The ethos of Shared Decision-Making resonates with that of geriatric medicine, putting the patient at the centre of decisions and incorporating personalised goals and preferences into decisions.

The tricky thing about sharing decisions in Treatment Escalation Planning is that these situations are high-stakes, uncertain and complex. This means that balancing autonomy with doing good, not causing harm, and wider resource considerations can be very challenging. Controversies around patient involvement in Treatment Escalation Plans have been widely broadcast in high-profile court cases and the popular press. So, are ‘good’ TEP decisions necessarily shared, and what does sharing actually mean?

There isn’t one ‘right’ way to make health decisions that will be entirely acceptable to all parties. How we practice now, and what patients want, is different from 50 years ago and will probably be different again 50 years from now. Current guidance from the Resus Council, GMC and others tells us that patients cannot demand treatment, but also encourages Shared Decision-Making. In answer to the question at the beginning: Treatment Escalation Planning is a medical decision… sort of. And the rules might change. Perhaps a better question might be: To what extent, in what way and why should Treatment Escalation Planning be a medical decision?

With all of this in mind, the STREAMS-C study aimed to understand clinician perspectives on Shared Decision-Making with older patients about Treatment Escalation Planning in hospital. We interviewed registrar and consultant physicians working in emergency medicine, general internal medicine, intensive care medicine and palliative care to find out their opinions. This study is part of a wider programme of research to understand the current state of play around sharing decisions in Treatment Escalation Planning. We believe that this research will be a useful stepping-stone to inform guidelines which are ethical, generally acceptable to different stakeholders, and practicable in a real-world setting.

If you are interested in complex decisions, bioethics, or acute frailty – or are just intrigued to know what other clinicians think about making Treatment Escalation Plans with patients – have a read of the original research paper in Age and Ageing.