Treatment Escalation Plans

What is a treatment escalation plan? 

A treatment escalation plan guides healthcare teams in making decisions regarding
your care and treatment where decisions need to be made quickly and you are not
well enough to speak for yourself.

A form is created to record the decisions you, your family/carer and your health
care team have made regarding the treatments that would be best for you in the
future of your care. It helps to ensure the right people have been included in
these important discussions.

You may have already created an Advance Care Plan to record important decisions
should you become ill or are dying such as, care arrangements, legacies, funeral, and
financial plans. A treatment escalation plan (or TEP) is part of this and relates only to
medical care and treatment.

It is important, although sometimes difficult, to think of the care and treatments we
would, or would not like to receive if we became ill. Having a conversation with your
health and care team and your loved ones to work through your wishes will help to
make these important decisions regarding what is right for you. They will be able to
understand your priorities and wishes and can support you now and in the future.

Thinking about these decisions in advance can apply particularly if you have complex
health needs, are nearing the end of your life, are considered at risk of sudden
deterioration or your heart/breathing suddenly stopping. You may have other
reasons to record your care and treatment preferences. Whatever the reason it is
important to discuss, record and communicate your wishes and conversations.

For more information, speak to any members of the health and care teams looking
after you. They will make sure you get the right support. You can search online for
more information about ‘Somerset Treatment Escalation Plan’ and to download a
copy of the form at

https://www.somersetccg.nhs.uk/for-clinicians/somersettreatment-
escalation-plan-step/

Who can help me with making a treatment escalation plan? 

Your healthcare teams will be able to help you to think about these decisions. The
Somerset TEP form has options, which will enable you discuss treatments that are
suitable for you and your medical conditions, for example:

• should I go to hospital, or not? If not, what would your care plan be?
• support arrangements available for you at home
• some specific treatments you do, or do not want to have e.g. supported
  breathing options, blood transfusions and use of certain medicine

Following discussion, your wishes will be recorded in your TEP and you will be given
a copy of your document. You will need to keep a copy safe at home and be able to
share it with any family and friends or representatives you wish to be aware of your
decisions. Your TEP will be recorded in your medical notes and made available to
health and care staff when needed, enabling any member of the team involved in
your care to access your plan at any time.

Why do I need a treatment escalation plan? 

In an emergency, health or care professionals may have to make rapid decisions
regarding your treatment, because you may not be well enough to discuss and make
choices. This plan empowers you to guide them on the treatments you would or
would not want to be considered for. It records those treatments that could be
important, or those that would not work for you.

Many treatments that can prolong life for some people carry a risk of causing harm,
discomfort, or loss of dignity to others. People can choose not to accept that risk if
the likelihood of benefit from treatment is small. This plan is to record your
preferences and agreed realistic recommendations for emergency situations, at
whatever stage of life you are.

A TEP is advisory. The doctor and team treating you will need to make decisions
based on your clinical condition at the time, but knowing your wishes will be
extremely helpful. The TEP cannot be used to ask for treatments that are not likely
be of benefit to you and would not be offered.

You must keep a copy of the plan to be immediately available to healthcare professionals called to help you in an emergency,whether you are at home or being cared for elsewhere. 

Ambulance crews, out-of-hours doctors, care home and hospital staff will then be
able to make quick decisions as to how best to help if they are able see your TEP
form in an emergency. Some people keep it in a prominent place such as fridge door
or kitchen noticeboard.

Who decides on resucitation?

Resuscitation is one of the decisions that will need to be considered when
completing a TEP. Resuscitation is the use of manual and medical treatments to try
to re-start a stopped heart and/or breathing. Your healthcare team can help explain
whether a resuscitation attempt might be successful for you.

If your healthcare team believe you might benefit from an attempted resuscitation
you are still allowed to refuse it. Mostly resuscitation is not successful and while a
person’s heart or breathing may re-start there may be a poor quality of life
afterwards. For this and other reasons, many people decide they do not wish to
have a resuscitation procedure attempted.

If you and your healthcare team decide you are for a ‘Do Not Attempt Cardio-
Pulmonary Resuscitation’ (DNACPR) order, this does not prevent you from coming
into hospital, or having other treatments, provided they are suitable for you and
wanted by you. Should you not agree with the advice the medical team have given
regarding attempted resuscitation, or other treatments, you are entitled to ask for a
second opinion.

Can I change my treatment escalation plan?

This is your plan. As things change for you, so can your TEP. You should review your
TEP regularly. As your health care needs increase, the plan helps to think about
what matters to you, making sure you understand what treatments your healthcare
team would be able to offer you.

Speak to your healthcare team regarding the changes you wish to make. They will
be recorded and communicated to hospital and ambulance teams.

Remember to also update any other plans, such as your Advance Care Plan. If you
have appointed a Lasting Power of Attorney (LPA) make sure they know about your
current TEP.

What about people who cannot decide their own plan?

In these circumstances, health and care professionals will need to follow the Mental
Capacity Act; which is a legal requirement. Professionals will need to initially
determine if you, the person, has or lacks mental capacity. Having mental capacity
means that you are able to make a decision for yourself. If a health or care
professional has any doubts regarding your capacity to plan about your care or
treatment, they will carry out the test of capacity.

If you are assessed as lacking capacity, then another person will have to plan in your
best interests. This could be someone you have appointed to act on your behalf
through a Lasting Power of Attorney, or, if you have not made plans in advance, the
professional responsible for working with you in relation to your future treatment
will have to decide what should happen in your best interests.

The professional must establish whether or not the decision can wait until you
regain capacity and are able to make that decision. They must involve you in the
decision as much as possible, taking into account your wishes and feelings and
talking to your friends and family to establish who is able to say what you would
have wished had you been able to make the decision yourself. If you do not have
anyone close and able give a view on what you would have wanted, then an
Independent Mental Capacity Advocate (IMCA) will be appointed to consider
and represent your best interests.

If your family, friends or an IMCA disagree with the best interest decision made by
the healthcare professional, they are able to challenge this