A Hebridean approach to Treatment Escalation Plans

‘I don’t want to be flown away. Can’t you look after me here?’ A frail elderly voice tries to start the hardest conversation in their lifetime. 

I work on a small Hebridean Island, and our practice covers our local community hospital. We have the extraordinary privilege of looking after our patients after they have been admitted to hospital. In many instances, we know our in-patients extremely well, their families and social networks, their occupation and their background.

We also have a very elderly population. In the last decade, the number of patients registered with our practice over the age of 90 has gone from one or two, to ten or twelve. More than a quarter of our population is over 65, and many have grown up with a much more paternalistic style of medicine, and live in hope that we will make the right decisions for them. 

For many, the first conversation about relevent and realistic goals is in crisis, at the bedside, in the community hospital. Most of us trundle through life, talking about shopping lists and the weather, keeping our fingers crossed that today, at least, no big decisions will be required. When the day arrives, the language and concepts are rudimentary for talking about life and death decisions. 

But for many Hebrideans, dying ‘off-island’ is the big fear. Away from relatives, from the gossip and visits of neighbours, away from the priest or minister, away from the Gaelic, and the comfort of being looked after by clinical staff who know just about everyone. Being transported home in a coffin on the ferry, and the relatives grieving at home without the remains to revere. 

So our discussion about transfer away becomes a discussion about many things. We can talk about the benefits of being in a big hospital with consultants and large radiology departments, whether knowing exactly what is wrong is going to be helpful. The community hospital can offer iv fluids, oxygen, antibiotics, time and care, which might be enough. We can talk about which clinical interventions might be useful. We can talk about the likelihood of dying, teh acceptance of risk, of using well-honed clinical acumen to guide treatment, and we can talk about what patients really want from their admission. 

On our Hebridean Treatment Escalation Plan, we have transfer at the top of the list, with all that it implies, with further investigation and intervention, leading the way for discussions about what goals the patient has for their clinical care. These are precious conversations between people who trust and know each other well. These are hard conversations, where neither patient nor clinician finds it easy to start talking about death as a possible outcome. These are the most important conversations that I have. 

So I answer: ‘No, we don’t have to fly you away, but we should talk about this.’