Treatment Escalation Plans: What Families Should Understand

When someone you love becomes seriously ill, every medical decision feels urgent and emotionally charged. One document that can make those moments clearer—yet is often misunderstood—is the Treatment Escalation Plan (TEP). A TEP is a concise clinical plan that outlines which treatments should or should not be started if the patient’s condition suddenly worsens. Understanding how TEPs work, why they matter, and how families can participate makes an enormous difference in ensuring that the care delivered truly reflects a patient’s wishes and best interests.

1. What exactly is a Treatment Escalation Plan?

A TEP is an agreed‐upon strategy between clinicians, the patient (where possible) and their family that specifies the ceiling of medical interventions to be used in an acute deterioration. Unlike a single‐issue order such as a DNR / DNACPR, a TEP covers a broad range of possible treatments, for example:

• Admission to intensive care or high-dependency units
• Use of mechanical ventilation or non-invasive ventilation
• Intravenous antibiotics or fluids
• Cardiopulmonary resuscitation (CPR)
• Blood transfusions or renal dialysis

Because it addresses multiple interventions, a TEP gives the clinical team immediate, actionable guidance, often summarized on one brightly coloured form placed at the front of the notes or uploaded to an electronic record system.

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2. Why do hospitals use TEPs?

1. Rapid decision-making: During a sudden decline there may be minutes—not hours—to decide whether to escalate to intensive care. A clear plan prevents delays and reduces unwanted interventions.
2. Patient-centred care: TEPs reflect the patient’s values, preferences and clinical realities, aligning treatment with what matters most to the individual.
3. Reduced conflict: When preferences are written down, families and staff are less likely to disagree at the bedside, easing moral distress on both sides.
4. Legal clarity: A documented plan helps clinicians meet their duty of care and the shared-decision-making standards set by the General Medical Council.

3. How is a TEP different from an Advance Decision or POLST?

Think of a TEP as the UK’s practical bedside counterpart to the broader documents you might store in an Advance Care Plan. Many hospitals integrate TEPs with digital systems so they appear automatically when the patient is admitted.

4. Core sections of a typical TEP

1. Patient details & diagnosis – Confirm identity and underlying condition(s).
2. Clinical baseline – Mobility, frailty score, current organ support.
3. Ceiling of treatment – Tick-boxes or free text indicating what is appropriate:
   • Ward-based care only
   • Non-invasive ventilation but not intubation
   • Full escalation to ICU
4. CPR decision – Often combined with DNACPR status.
5. Advance statements / legal docs noted – e.g., a Lasting Power of Attorney or Advance Decision.
6. Discussion record – Who was involved, what was said, agreement reached.
7. Review date & signature – TEPs should be revisited as conditions change.

5. What families should do before a crisis

a. Start conversations early.
Use routine appointments or family gatherings to explore values: “What makes life worth living?” Tools like the Evaheld Legacy Vault help capture these reflections in writing, audio or video so they’re available if capacity is lost.

b. Learn the medical realities.
Read trustworthy resources such as the BMJ’s TEP guide for patients or your local hospital’s leaflet. Understanding terms like “non-invasive ventilation” makes discussions less intimidating.

c. Identify a spokesperson.
If your loved one has appointed a Health & Welfare Attorney, ensure you have the paperwork ready. If not, agree who will act as the main contact so messages stay consistent.

d. Bring existing documents.
Hospitals can upload Advance Decisions or DNACPR forms into the electronic TEP. A single folder—digital or physical—saves frantic searching during admission.

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6. How families participate during TEP discussions

1. Ask for plain language.
   “Can you explain what ‘full escalation’ means for Mum in practical terms?”
2. Explore best- and worst-case scenarios.
   Clinicians can outline likely outcomes: survival chances, hospital stay length, impact on quality of life.
3. Share personal knowledge.
   Families provide context clinicians can’t see: hobbies, spiritual beliefs, past statements like “I never want to be kept alive on machines.”
4. Clarify reversible vs. irreversible.
   Some treatments (e.g., antibiotics) can be trialled and stopped. Others (e.g., intubation in advanced dementia) may cause prolonged suffering.
5. Document questions.
   Write down agreed answers; many hospitals add family comments to the TEP form.
6. Confirm review triggers.
   Ask: “When will this plan be updated? Who contacts us?”

7. Special considerations for children and young adults

• Best-interest meetings involving paediatricians, parents and, where appropriate, the young person.
• Paediatric TEPs (sometimes called ReSPECT forms) include sections on school, play and developmental impact.
• Transitioning teenagers should have their TEP revisited as they shift to adult services—guidance from the Royal College of Paediatrics and Child Health stresses re-assessment.

8. Common myths—and the facts

9. Making the plan visible and portable

1. Hospital records: Ensure the TEP is scanned into electronic notes.
2. Home copies: Keep the latest version near the front door or on the fridge for paramedics.
3. Care homes / hospices: Provide a copy on admission; many settings require it before accepting a transfer.
4. Digital access: Some regions upload TEPs to shared care records so out-of-hours doctors can see them instantly. Platforms such as the Evaheld Story Vault let families store both clinical documents and the personal narratives behind them.

10. When disagreements arise

Despite best efforts, families and clinicians sometimes clash. Steps to resolution:

1. Request a senior review. Consultants can revisit clinical facts and re-explain options.
2. Use mediation services. Many NHS trusts have patient liaison or ethics teams.
3. Second opinions. Another clinician may clarify prognosis.
4. Legal routes. In rare cases, the Court of Protection decides. Clear, early documentation usually prevents reaching this stage.

11. Practical checklist for families

12. The emotional dimension

A TEP conversation isn’t merely administrative—it surfaces fears about suffering, dependency and death. Families often experience relief after the plan is finalised, reporting less anxiety about “doing the wrong thing.” Clinicians, likewise, feel supported when clear guidance exists. If emotions run high, request a quiet room or involve chaplaincy or counselling staff.

13. Key take-home messages

• TEPs personalise emergency care by setting clear ceilings of treatment aligned with a patient’s wishes and clinical realities.
• Early, honest conversations among patients, families and clinicians are the cornerstone of a good plan.
• Portability and visibility ensure the TEP is acted upon wherever deterioration occurs.
• Regular reviews keep the plan relevant; it’s a living document, not a one-off form.
• Digital tools such as Evaheld can preserve both the clinical plan and the personal story behind it, giving future clinicians and loved ones rich context.

Discussing a Treatment Escalation Plan may feel daunting, but it ultimately offers families clarity and peace of mind. By understanding its purpose and process, you can advocate effectively for care that honours your loved one’s values when it matters most.

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