Personal treatment plans in emergencies

PATCH supported work exploring whether personal future care plans can help patients, families, and staff reach clearer decisions during clinical deterioration and emergency care.

The aim is to move beyond a “one size fits all” approach by agreeing a plan through careful discussion in advance. When a crisis happens, decisions can then reflect what matters to the patient and what is medically appropriate.

What a treatment escalation plan is

A treatment escalation plan (TEP) is a short, easy to read summary of a patient’s priorities for their current hospital stay. It is held in the patient’s notes or electronically, so the team caring for them can see it quickly. For that admission, it sets out the goals of treatment and which individual treatments are or are not appropriate.

A TEP goes further than a traditional Do Not Resuscitate order, which was narrow in scope and open to misunderstanding. It covers the wider picture of care, can be reviewed as often as needed, and is updated as a patient’s needs change.

The problem it addresses

Emergency departments and acute wards are built to save lives. Staff are highly trained, follow treatment guidelines, and are careful to avoid risk. For many patients this is exactly right. For some, it is not. When palliative treatment is the most important need but is hard to arrange quickly, the default is often admission to hospital and more intervention.

A TEP helps the team agree what should happen if a patient deteriorates, including when comfort and symptom control matter more than further intensive treatment. Symptom management, including palliative care, is appropriate for every patient.

What the evidence shows

Research has consistently found that treatment escalation plans reduce avoidable harm to patients in hospital. A study led by Dr Robin Taylor and colleagues, whose work PATCH supported, reviewed 300 hospital deaths and found that the rate of medical harms was much lower for patients who had a TEP alongside a resuscitation decision than for those with a resuscitation decision alone or no plan at all. ^[1]

This built on an earlier evaluation of a similar tool, the Universal Form of Treatment Options, which also reported a significant reduction in harms compared with using a resuscitation order on its own. ^[2] Evidence like this helped answer the doubts that TEPs met when they were first introduced.

A national plan for Scotland

Treatment escalation plans are now used in almost all of Scotland’s major hospitals. A national treatment escalation plan for NHS Scotland was finalised in June 2024. It is designed to support clear conversations with patients and families, often using the REDMAP framework recommended in Scotland, and it records the level of care agreed for the admission.

PATCH’s role

PATCH supported the development of treatment escalation plans, including research that provided evidence of their benefit to patients. That evidence helped build confidence in TEPs among clinicians and managers, and supported their adoption across Scotland.