Treatment Escalation Plans (TEP) in the Elderly
A Treatment Escalation Plan (TEP) is a formal record of what treatments are appropriate if a patient deteriorates.
It is wider than DNACPR, because it covers all aspects of escalation (e.g. ward vs ICU, ventilation, antibiotics, fluids).
In the UK, the ReSPECT form (Recommended Summary Plan for Emergency Care and Treatment) is the national standard.
🧑⚕️ Key Components of a TEP Form
- 👤 Patient details: Name, NHS number, baseline condition, frailty score.
- 🧠 Capacity status: Does the patient have capacity to contribute?
- 🎯 Goals of care: Curative, life-prolonging, or comfort-focused?
- ❤️ CPR decision: Attempt CPR or DNACPR?
- 🏥 Ceiling of care:
- Ward-based only (fluids, antibiotics, oxygen).
- High-dependency care (CPAP, NIV, vasopressors short-term).
- ICU (intubation, ventilation, invasive monitoring).
- 💊 Specific treatments: e.g. dialysis, chemotherapy, surgery.
- 📝 Documentation: Clinician signature, date, patient/family discussion record.
⚖️ Ethical & Legal Principles
- 🧠 Capacity (MCA 2005): involve patient if possible.
- 👥 If lacking capacity: best-interests decision, involve family/carers, IMCA if no relatives.
- 📜 ADRT & LPA: legally binding if applicable.
- ⚖️ Court of Protection: if dispute cannot be resolved.
📊 Example of Escalation Planning (ReSPECT form style)
| Domain |
Options |
Example for Frail 85-year-old |
| CPR |
Yes / No (DNACPR) |
No CPR – burdens outweigh benefits |
| Ward Care |
Fluids, antibiotics, oxygen, blood transfusion |
Yes – appropriate |
| Respiratory support |
Oxygen, CPAP, NIV, intubation |
Oxygen only – not for CPAP/NIV/ICU |
| ICU |
Yes / No |
No – not for ICU escalation |
| Comfort |
Palliative measures, symptom relief, place of care |
Yes – prioritise comfort if deterioration continues |
📝 OSCE / Exam Pearls
- State clearly: “TEP is wider than DNACPR – it sets ceilings of care.”
- Mention ReSPECT form as the UK standard.
- Always link to patient’s values: “What matters most to you?”
- Involve patient/family; stress this is not about “doing nothing” but about doing what helps.
🎯 Key Takeaway
A TEP form provides clarity on what to do if a patient deteriorates.
It prevents burdensome, futile interventions while ensuring appropriate treatment continues.
It is always individualised, patient-centred, and part of good geriatric practice. 🌟
