Treatment Escalation Plans and Cardiopulmonary Resuscitation Decisions

What is a Treatment Escalation Plan (TEP)?

A TEP is a document that records which treatments would and would not be offered if you became more unwell while in hospital. It is individual to your circumstances, and outlines treatments that your medical team believe would be helpful, and those that would not.

It is written by your doctor, following a conversation with you and/or those close to you. During this discussion, your healthcare team will discuss your health and explain which treatments could be helpful if you became more unwell, and those that would not. Your team will provide the information you need about your health and the treatments available. You will have the opportunity to express your wishes regarding your treatment and care, which your team will take into account when making any decisions.

A TEP aims to ensure that you receive the best possible treatment for your individual situation. It cannot be used to request or demand treatments that would not help you.

Why is it a good idea to have a TEP?

The decisions written down on a TEP will guide the health professionals looking after you if you become more unwell, especially in an emergency. By following the guidance on your TEP, the team can ensure you receive the care that is right for you. This includes providing any treatments that may help you, and avoiding any that would not help, and may cause you harm or discomfort.

Who should have a TEP?

Any patient with advanced or complex health problems, who is at risk of suddenly becoming more unwell, should have a TEP.

What types of treatment will be considered and put on a TEP?

The treatments considered will depend on why you have come to hospital and your underlying medical condition(s). If you are well enough to take part in discussions, the team will clearly explain the treatment options that are suitable for you.

Some of the treatments that they might discuss include:

• antibiotics
• blood transfusions
• admission to intensive care
• cardiopulmonary resuscitation (CPR) if your heart or breathing stops (see Cardiopulmonary Resuscitation (CPR) section below for more information)

Some people might prefer a focus on comfort, with less intensive medical treatments, while others will want every possible treatment. The team will record which treatments would be appropriate for you based on whether they would help you, and your preferences.

Is a TEP only about not being given certain treatments?

No. A TEP will ensure that it is clear which treatments should be considered if you were to become more unwell, in addition to those which should not. When you have a TEP you will continue to receive all treatments that will benefit you and that you accept.

Can I use a TEP to insist on having treatment?

No. The decision whether or not to offer any medical treatment, from antibiotics to CPR, can only be made by your healthcare team. Neither you nor those close to you can demand a treatment that healthcare professionals believe will not work. However, you can make your preferences for treatment clear, and your medical team will consider your wishes when making any decisions.

If you do not understand why a particular treatment is not going to work, please ask your team to provide further information.

What is Cardiopulmonary Resuscitation (CPR)?

Cardiopulmonary resuscitation (CPR) is a medical treatment used when someone suddenly collapses because their heart and/or breathing have stopped (cardiac arrest). CPR sometimes, but not always, gives people the chance of recovery.

CPR may include:

• repeatedly pushing down very firmly on the chest
• electric shocks to try to restart the heart
• insertion of a tube into the windpipe to help to breathing, which may later be attached to a machine

When your healthcare team discusses and makes decisions about a TEP with you, they will consider whether or not CPR might be a beneficial treatment for you.

Why shouldn’t everyone have CPR?

CPR often fails to restart the heart and breathing – only about 2 out of 10 patients in the general population survive long enough to leave hospital after CPR. These figures are much lower for people who are ill or frail. CPR will not prevent death when the heart and breathing stop as part of the natural dying process. In some cases, CPR can prolong dying or suffering and cause harm.

CPR is not an appropriate treatment when it will not stop a person from dying, so if you are seriously ill and near the end of your life, there is no benefit from CPR. CPR at the end of life can prevent a peaceful death. For these reasons, CPR is not offered in these circumstances.

Who will decide if CPR should be attempted?

All patients are given CPR unless their healthcare team believes that CPR is not going to work. As CPR is a medical treatment, the decision whether or not to offer CPR is made by your medical team. The consultant in charge of your care is legally responsible for making the decision.

How is a decision about CPR made?

To make a decision about whether CPR is likely to be successful for you, your medical team will consider your current condition and overall health. Your team will talk to you about your health and explain the reasons for a decision about CPR. As with all medical treatments, the team will consider the potential risks and benefits of CPR. With your permission, those close to you can also be involved in this discussion, but they cannot make the decision.

What happens if a decision is made not to attempt CPR?

It is important to remember that a decision not to attempt CPR only applies to CPR and does not mean stopping or not offering any other treatments. You will continue to receive the best possible care, including other appropriate treatments, as agreed in your TEP.

Your healthcare team will inform you of the decision and ensure that you understand why the decision was made. They will speak to those close to you if you wish.

A ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) form will be completed and placed in your medical records alongside your TEP.

I do not want CPR if my heart or breathing stops. What should I do?

If you would not want CPR, please discuss this with your healthcare team. They will explore, document and share your wishes (with your consent).

See the section below titled Frequently Asked Questions for more information about how your wishes can be shared with healthcare professionals using a Universal Care Plan.

If you want to make your wish not to have CPR legally binding, you can make an Advance Decision to Refuse Treatment (ADRT). For more information about an Advance Decision to Refuse Treatment (ADRT) please speak to your healthcare team or visit the NHS website.

What if I want CPR but I am told it will not work?

No doctor will refuse your wish for CPR if it is considered to be an effective treatment option for you. If your healthcare team feel that CPR would not work, you or those close to you cannot demand CPR.

If your medical team believes that CPR could restart your heart and breathing but is likely to leave you severely ill or disabled, your doctor will discuss this with you and ask for your views. You can also ask those close to you to support you and give their opinion.

If you are unhappy with a DNACPR or TEP decision, UCLH is happy to arrange a second medical opinion from another senior doctor. Your doctor can tell you about this process.

What if I don’t want to talk about any of this?

Your healthcare team will always offer you the opportunity to be involved in decisions about your treatment, and if you agree, encourage those close to you to be present during discussions.

If you do not wish to be involved in discussions about your treatment, including CPR, those close to you can speak directly to your healthcare team with your consent.

If you do not want others to know about your condition or the decisions made about your treatment, please inform your healthcare team so they can respect your wishes and confidentiality.

Your medical team are legally obliged to inform you of a DNACPR decision, unless you specify that you do not want to be involved in this decision.

What if I am too unwell to talk about this?

If you are too unwell and unable (lacking mental capacity) to discuss TEP and CPR decisions, your healthcare team will talk to those who are close to you to help understand what you would have wanted. Your family, friends and carers cannot legally make decisions on your behalf, but can contribute to the process of making a decision in your best interests. If you have appointed a Lasting Power of Attorney for Health and Welfare they will have a key role in this process. If those close to you are not available and it is an emergency, the healthcare team will make decisions in your best interests.

You can find more information about Lasting Power of Attorney on the GOV.UK website.

When will these decisions be made?

National guidance recommends that these discussions take place shortly after admission to hospital. Sometimes your current health will require decisions to be made more urgently than at other times. We will always try to involve you and/or those close to you in these discussions if possible.

What if I change my mind or my situation changes? Your thoughts about treatments that you do or do not want may change over time. Please make sure you update your healthcare team and those close to you.

Decisions about treatment, including CPR, are reviewed regularly by your healthcare team, taking into account your health and your wishes. If your condition changes your healthcare team may talk to you and/or those close to you about updating your TEP.

What happens to a TEP and DNACPR form after I am discharged from hospital?

The Universal Care Plan is a digital record of your care plan including TEP and CPR decisions. It can also include your broader wishes and preferences for your future care and what matters to you. This service is currently only available within Greater London. With your consent, a healthcare professional can create and update your Universal Care Plan. It will be visible to healthcare professionals across London including your GP, London Ambulance Service, NHS 111 and hospital teams. If you live outside Greater London you can speak with your GP to ask what is available in your local area. You can find more information about Universal Care Plan (UCP) visit: ucp.onelondon.online/patients

Your hospital discharge letter will also inform your GP of decisions made in hospital regarding your treatment. Following a discussion, some patients are discharged home with a paper copy of a DNACPR form, to be kept in the place where they live. This is called a community DNACPR form. Your GP can also complete a community DNACPR form. It is important to tell people close to you where to find your DNACPR form in case a healthcare professional needs to see it.

If you are discharged from hospital and return at a later date, the healthcare team will review your current situation to make an appropriate decision regarding treatment.

Is a TEP or DNACPR decision legally binding?

No. The decisions recorded on these documents are used by healthcare professionals to guide treatment when you are very unwell, but are not legally binding. The information will be used to ensure that you receive the appropriate treatment in the situation at the time.

In England and Wales, to legally refuse treatments you need to make an ADRT (Advance Decision to Refuse Treatment). You need to ensure that your team have a copy of your ADRT in your medical record.

Who else can I talk to about this?

In addition to your healthcare team, you may want to talk to other people about the decisions made in relation to your treatment. They include:

• family, friends and carers
• your GP
• patient support groups e.g. Macmillan Cancer Support, Age UK
• spiritual or faith advisers
• independent advocacy services

It is a good idea to think about and plan for the future, in case you become too unwell to make decisions about your care. That way, you can still have your say in your treatment.

Talking to your healthcare team about your TEP will provide you with a better understanding of the treatments that are likely to be helpful for you in the future and those which are not. It will also provide you with the opportunity to consider and inform your team about any particular treatments that you don’t want to receive. This leaflet focuses on DNACPR and TEP decisions. Planning your future care involves much more, including your personal preferences, values, and what matters most to you. You can find out more on our Planning Your Future Care page.

You can view future care planning leaflet under patient information via this link: Transforming End of Life Care Team

Here are some additional things that you may consider:

• If you become sicker, how much would you be willing to go through for the possibility of gaining more time?
• Is there a point in your illness when you would want to be treated at home, and would not want to return to hospital?
• Where would you want to be cared for towards the end of your life?
• Do those close to you know your priorities and wishes?

Talking about this can be difficult, but if you feel ready, speak with your healthcare team and those close to you.

Many resources are available to provide additional information to help you to make and document decisions about your care.

For more information about Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions visit: NHS UK – Do not attempt cardiopulmonary resuscitation (DNACPR) decisions

For more information about Planning your Future Care please see our dedicated service page on our website. Or visit Planning ahead for end of life care on the NHS website.

For more information about Universal Care Plan (UCP), visit: Universal Care Plan for London​​​​​​

You can find more information about Advance Decisions to Refuse Treatment (ADRT) on the NHS website.

For more information on Lasting Power of Attorney, visit: GOV.UK – Make, register or end a lasting power of attorney

For more information about capacity (the ability to make decisions for yourself) visit: NHS UK – Assessing capacity

If you feel that you have not had the chance to have a proper discussion with your healthcare team, or are unhappy with the discussions that you have had, please speak with your team.

The Patient Advisory Liaison Service (PALS) is a service that offers support, information and assistance to patients and visitors. They can provide help and advice if you have a concern or complaint that staff have not been able to resolve.
Email: uclh.pals@nhs.net
Telephone: 020 3447 3042

UCLH switchboard: 020 3456 7890