Decision-making around Treatment Escalation during Acute Deterioration

Campling, Natasha, Cummings, Amanda, Myall, Michelle, Lund, Susan, May, Carl R., Pearce, Neil and Richardson, Alison (2018) Decision-making around Treatment Escalation during Acute Deterioration. In Palliative Medicine. vol. 32, SAGE Publications. p. 74 . (doi:10.1177/0269216318769196).

Abstract

Background: Making and recording decisions about treatment and care in the face of uncertainty surrounding pathophysiological deterioration leading to death in hospital is often problematic and at times contentious. To date focus has been on do not attempt cardiopulmonary resuscitation (DNACPR) orders and advanced care plans as methods to facilitate decision-making at times of crisis. However very little is known about the decision-making processes themselves.
Aim: To describe how decision-making processes interrelate with the sequence of events and resources mobilised, for individuals who die during inpatient admissions.
Methodology and methods: An in-depth retrospective case note review. Data were analysed utilising: care management process mapping via annotated timelines involving key events for each case; and directed content analysis.
Sample: The review built on an initial death certificate review form audit of all patients (n=911) who died in one acute hospital over a six month period (Jan-July 2015). Case notes of a 5% sample of patients (n=45) were obtained. Purposeful stratification was undertaken by: DNACPR, palliative care involvement, intensive care and high dependency management, evidence of escalation/de-escalation discussion/decision, and illness trajectory. The age range of patients was 38-96 years, with 23 female and 22 male. Length of admission ranged from < 24 hours to 97 days.
Findings: Four care management trajectories were identified mapping clinical decision-making processes. These were: early de-escalation due to catastrophic occurrence; treatment with curative intent throughout; treatment with curative intent until a significant point; and early treatment limits set due to pre-admission morbidity.
Conclusion: All trajectories demonstrated: clinical complexity and uncertainty (via multiple co-morbidities, new diagnoses, and challenging management e.g. of sepsis and frailty); impact of multiple clinician involvement (multi-speciality/professional); impact of family involvement (triggering decisions via discussion with teams, most apparent when absent); and the influence of clarity and visibility of management plans. Our data suggests that treatment escalation plans, a method to involve patients and families in escalation planning before crisis situations occur, could add value if used more widely.

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Contributors

Author: Natasha Campling

Author: Amanda Cummings

Author: Michelle Myall

Author: Alison Richardson

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