Treatment Escalation Level |
Poor oral intake (often with aspiration risk) Management Plan and Wishes : |
ITU |
Trial of community management where feasible and safe If poor diet and fluid intake cannot be managed in the community, admit to hospital for further investigation and intravenous fluids +/- supportive nutrition |
Hospital |
Trial of community management where feasible and safe. If poor diet and fluid intake cannot be managed in the community, admit to hospital for further investigation and intravenous fluids +/- supportive nutrition |
Home |
Declining oral intake is a common symptom of end stage frailty & other illnesses. Artificial nutrition is not indicated, and so hospital admission would not be beneficial. Follow any specific SaLT or dietetics plan (if one is in place). Manage at home with supportive measures by encouraging diet and fluids. Offer food and drink the person enjoys Offer regular mouthcare Trial oral nutritional supplements if appropriate Consider reversible causes (such as infection, constipation, poor dentition, oral thrush) that could be treated with oral medications. Consider involving local community urgent response service/virtual ward/frailty team for further monitoring and support. If oral intake continues to decline despite above measures, then consider whether this an end of life situation. If so, arrange anticipatory/palliative medications and move to comfort measures. |
Comfort |
Consider whether this is an end of life situation. Anticipatory medications in place, use as required. Food/flavour, if requested and able. Administer mouth care including oral cleaning, ice chips, occasionally artificial saliva to alleviate symptoms of dry mouth. Thirst is rarely a feature. Moisten the lips/lip moisturizers Ensure Community Team supporting and Package of Care sufficient to support patient and family needs. |
Treatment Escalation Level |
INFECTION (Chest/Urine/Unknown Source) Management Plan and Wishes : |
ITU |
Consider source of infection & starting appropriate oral antibiotics. If deteriorating on oral antibiotics or not feasible, then admit to hospital for possible IV antibiotics. ITU admission will be decided in hospital as appropriate. |
Hospital |
Consider source of infection & starting appropriate oral antibiotics. If deteriorating on oral antibiotics or not feasible, then admit to hospital for possible IV antibiotics. Does not wish to be admitted to ITU. |
Home |
Consider source of infection & starting appropriate oral antibiotics. Consider involving local community urgent response service/virtual ward/frailty team for further monitoring and support. If deteriorates despite oral antibiotics, consider whether this is an end of life situation. Move to comfort measures |
Comfort |
Consider source of infection & starting appropriate oral antibiotics, if feasible and wanted. Anticipatory meds. in place, use as required. Ensure Community Team supporting and Package of Care is sufficient for patient & family needs. |
Treatment Escalation Level |
Delirium Management Plan and Wishes : |
Notes |
ITU |
Investigate possible causes. Manage at home as appropriate. If deteriorating on oral treatment, then admit to hospital for further investigation. ITU admission will be decided in hospital as appropriate. |
Consider whether appropriate if past history of dementia, a progressive neurological or palliative condition |
Hospital |
Investigate possible causes. Manage at home as appropriate. If deteriorating on oral treatment, then admit to hospital for further investigation. Does not wish to be admitted to ITU. |
See above. Patient, or family if LPOA for H&W is in place, may also wish to limit other treatments. |
Home |
Investigate possible causes. Manage at home as appropriate. If deteriorates despite oral treatment, consider whether this is an end of life situation. |
This option is only likely to be appropriate on a background of a palliative diagnosis or expected recurrent delirium. Seek specialist advice as appropriate. |
Comfort |
Anticipatory meds. in place, use as required. Ensure Community Team supporting and Package of Care is sufficient for patient & family needs. |
Treatment Escalation Level |
Fall with suspected fracture Management Plan and Wishes : |
Hospital |
Offer analgesia for any pain. Assess post fall and convey to hospital if concerns about a fracture. |
Home |
Offer analgesia for any pain and prescribe a supply. Assess post fall and only convey to hospital if concerns about a long bone fracture are very difficult to pain control without fixation). If fracture unlikely, stable or comfortable, wishes to remain at home. Consider reversible causes of a fall (such as infection, constipation, urinary retention) that could be treated with measures at home. Consider involving local community urgent response service/virtual ward/frailty team for further monitoring and support. If concerns about a significant fracture, consider referral to hospital for XR assessment, but discuss with patient and/or family first. Plan to be discharged back home as soon as possible after assessment, unless operative management is indicated. Not to remain in hospital for investigation or management of unrelated issues unless agreed with the patient and/or family. |
Comfort |
Only convey to hospital if concerns about significant painful fracture (e.g. neck of femur) where operative management would be considered and after discussion with patient and/or family. Consider any operative management only as a palliative procedure to relieve pain and with discharge home as soon as practicable. If no concerns about significant fracture, treat any pain with analgesia. Consider whether this is an end of life situation. Anticipatory/palliative medications in place, use PRN. Move to comfort measures. |
Treatment Escalation Level |
Management Plan and Wishes : |
ITU |
ITU admission will be decided in hospital as appropriate. |
Hospital |
Does not wish to be admitted to ITU. |
Home |
Is aware of the risk of an intra-cranial haemorrhage and would not want active neurosurgical treatment. Please do not convey to hospital for brain imaging. Manage conservatively. If deteriorates, consider whether this is an end of life situation. Move to comfort measures |
Comfort |
Anticipatory meds. in place, use as required. Ensure Community Team supporting and Package of Care is sufficient for patient & family needs. |
Treatment Escalation Level |
Management Plan and Wishes : |
Hospital |
|
Home |
|
Comfort |
Treatment Escalation Level |
Management Plan and Wishes : |
Hospital |
|
Home |
|
Comfort |