Do Not Resuscitate – Completing a TEP
Firstly, what on earth is a TEP? Many of us will have heard of DNR orders, but have no idea what a TEP is, it stands for Treatment Escalation Plan and is the NHS document regarding end of life and resuscitation.
It has 3 sections; part A looks at whether this patient is at the end of their life with a poor prognosis and starts the question “Would you be surprised if this patient died within the next 6 – 12 months?”. When I talked to healthcare professionals about death and dying, they will often say that they cannot predict when someone is going to die. They can try and they will often get it right or close to being right, but not always. People can unexpectedly rally and recover and continue to live for months or years. I had a client who was Catholic and approximately annually the priest was called in the early hours of the morning to give her last rites and asked not to wait until office hours as she wouldn’t survive until then. She finally succumbed in the 4th year, having survived last rites 3 times!
The next bit of section A looks at any advanced decisions that person made and whether they have the capacity to participate or make the decision themselves and if they haven’t, it allows the doctor to decide whether or not to resuscitate in the event of cardiorespiratory arrest. In other words, is someone going to do CPR (chest compressions and restart their heart if it stops).
Part B then looks at a slower less dramatic decline and considers the circumstances “If the patient is currently very unwell or in the event their condition deteriorates”. There is a series of boxes to tick Yes/No including some that are only relevant in hospital (aka acute setting). The 5 questions for outside of hospital are:
- Is admission to acute hospital appropriate?
- Are IV fluids appropriate?
- Are antibiotics appropriate?
- Is artificial feeding appropriate?
- Is De-activation of Implantable Cardioverter Defibrillator (ICD) appropriate?
TEPs are important documents, they are life and death decisions. They are not however written in stone and can be changed by a doctor at any point in time that circumstances change. And when circumstances change a new TEP is completed and placed in the patients notes. Until it is changed, the current TEP will be followed by the healthcare professionals looking after that person, including doctors, nurses and paramedics.
I’ve seen lots of these completed, I’ve even been part of conversations around end of life in vague non-specific terms, but I’ve yet to see a doctor complete one in full consultation with the family, so they clearly understand what a tick in each of the boxes will mean. It does have to be completed by a doctor, it is their signature on the form, but even when there is a health and welfare attorney with authority to make decisions about life sustaining treatment, the doctor still doesn’t fully consult with the attorney, or at least I’ve never yet seen that. This means that they can get it wrong! Not every family member wants to discuss this in detail and if they don’t that’s fine, that’s their choice. But they should be given the option!
Part C is about organ donation, so is only relevant at the time when the other decisions are all over!
TEPs can be scary, they deal with circumstances that family members don’t want their loved ones to be in – very poorly! If anyone needs support in dealing with a TEP or understanding it, then let me know. I’ve been involved in others and I understand.