25 Treatment escalation plans in cancer care during the COVID-19 pandemic

ABSTRACT

IntroductionTreatment escalation plans (TEP) enable the documentation of senior clinician-led and patient-centred advance care planning. The COVID-19 pandemic highlighted the importance of early decision-making regarding treatment escalation and early palliative care involvement. At the Royal Marsden Hospital, a TEP form was created collaboratively by Palliative Care and Acute Oncology teams in response to the pandemic. It detailed current issues including cancer diagnosis, possible clinical interventions and prognosis.MethodsA retrospective study was performed of TEP completion in non-elective admissions from 6th-27th April 2020. We reviewed patient factors including prognosis, DNACPR status, palliative care involvement and patient outcomes using electronic patient records and TEP forms. A survey was emailed to all clinical staff for feedback on the TEP forms and their impact.ResultsOf the 197 non-elective admissions, 105 (53.3%) had a TEP completed. Compared to those without a TEP, patients who had a TEP completed were more likely to be on a non-curative than curative treatment pathway (91/105 (86.6%) vs 50/92 (54.3%;p<0.001 χ2), have a documented DNACPR status (78.1% vs 18.5%;p<0.001 χ2), have palliative care input (55.2% vs 25%;p<0.001 χ2) or died (18.1% vs 6.5%;p=0.015 χ2) during admission. Suspected or confirmed COVID-19 infection did not impact upon TEP completion in this cohort. The online survey was completed by 59 staff members including 30 consultants. 74.5% respondents felt that the TEP form had a positive impact on patient care, with comments on possible refinements and improvements given.ConclusionsIn a specialist cancer centre rates of completion of TEP forms were higher in non-curative patients receiving increased levels of palliative care input. The TEP form had a perceived positive impact on patient care amongst clinicians, although overall uptake was disappointing. We plan to update the TEP form in response to feedback, and re-audit after 6 months.