For many patients in hospital, their treatment is now more and more complex.

Patients are often seen by a number of doctors and nurses from different specialities, particularly if the patient has a number of different, although perhaps related, medical problems.

Given this complexity, difficulties can sometimes arise in communicating effectively between clinical teams, and also between clinical staff and patients or relatives, despite the best efforts of all.

As some people might expect; any difficulties in communication can be regarded as more of a problem when dealing with issues around ‘serious medical treatment’ such as cardiopulmonary resuscitation (CPR), transferring patients to critical care unit, or providing any other treatment that might have significant consequences patients.

For many people who have been admitted to hospital for a routine procedure it would be easy for us to assume that should we have an unexpected deterioration in our condition, we would want all full and active treatment that the hospital could offer.

However some patients might have concerns about certain treatments, and in some cases they might wish to refuse them. For example with the use of blood products or other treatments, even if this means they are at more risk of dying without it.

Some people will go as far as to document in writing any treatment they would wish to refuse in an ‘Advanced Decision to Refuse Treatment’ (ADRT). Others might appoint someone they know and trust to have Power Of Attorney who can speak on their behalf if they are too ill to express their wishes clearly.

Discussing CPR with patients, and - if they wish, with their relatives, can be a difficult experience for everybody. Sometimes patients will request not to take part in this discussion at all, others will be very keen to engage in this conversation with their doctor or nurse.

Some patients during the course of such a conversation might be surprised to hear that their illness has become more advanced or life-limiting, and others might simply have their previous knowledge of their illness reinforced.       

Every patient is unique, as is their clinical condition; and more often now, it is recognised that clinical decision making in modern medicine is more complex than simply making a recommendation about CPR.

Whether a patient should receive cardio-respiratory resuscitation (being placed on a life-support machine) in the event of their heart and lungs’ not working is an example of this.

Significant national audits of people receiving CPR in hospital describe this as a ‘grey’ area.

For instance, some patients might benefit from antibiotic therapy or other treatments, but are thought to be too sick or suffering from an illness that is too advanced for CPR or other treatments to be successful.

Many people in hospital can be very frail and the clinical team has to identify patients who might go on to deteriorate further, but for whom CPR or other interventions will not be effective and might actually make life worse for the patient.

This decision making can be difficult and it can be a challenge to explain to patients using language that is easy to understand whilst taking into account the sensitive nature of such a conversation.

In order to aid communication between clinical teams and patients, and their relatives, the Trust has changed the electronic ‘Do Not Attempt Cardio-Respiratory Resuscitation’ (DNACPR) template to incorporate a new feature called Treatment Escalation and Limitation (TEAL) within our electronic Prescribing and Investigation Communication System (PICS).

TEAL records recommendations on which treatments to limit and those that can be escalated, and these can only be made by senior medical staff (registrar and above) but can be viewed by all hospital staff with access to PICS.

Any discussions with patients and relatives around the provision or withholding of serious medical treatment will continue to be documented in the patients records – either by writing in the notes or by using another new electronic template called ‘Significant Conversations’.

Our hope is that TEAL will help not just help in aiding clinical decision making but it will help improve communication between clinical teams, as well as between patients, their families and their doctors

Dr John Speakman is the Lead Palliative Care Consultant at UHB and also works at St Mary’s Hospice in Selly Oak, Birmingham.  

Dr Speakman has been nominated for the Kate Granger Awards for Compassionate Care 2015 at the Health and Innovation Care Expo in Manchester on Thursday 3 September 2015.

For more information about the Expo, please visit the NHS England Ecpo website (see below).