1. A brief introduction to
Recommended
Summary
Plan for
Emergency
Care and
Treatment
Alison Richardson
Member of ReSPECT Working Group
Professor of Cancer Nursing & End of Life Care
University of Southampton &
University Hospital Southampton
Good afternoon
Welcome on behalf of NIHR CLAHRC Wessex. Pleased to be able to support organisation of this meeting to give opportunity for a wide range of stakeholders to consider the ReSPECT process and debate, if and how, might be implemented across our geography.
Speaking in my capacity as working group member contributed to development. Fed in learning from Wessex CLAHRCs work on Treatment escalation planning with several organisations: Hampshire Hospitals, Salisbury, Southampton and discussions with broad range of stakeholders, for example Macmillan GP facilitators.
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2. ReSPECT Background to ReSPECT What ReSPECT is (and what it isn’t)
Aims of ReSPECT
Key parts of the ReSPECT process
Implementing ReSPECT
Short presentation to cover off the background, how it came about. What it aims to do and what the process comprises. Clsoe some information on expectations around implementation.
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3. Background — the evidence
October 2014
DNACPR
from
best evidence to
best policy and practice
hsdr/volume-4/issue-11#abstract  
The ReSPECT project started in 2014, when the results of a systematic review of DNACPR decisions and documents were presented at a meeting at the Royal Society of Medicine, by a team from Warwick
University.
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4. Background DNACPR decisions and discussions have led to:
Negative patient/public perceptions
Negative clinicians’ perceptions
Complaints
Litigation
Negative media reports
Some of the headline findings were that DNACPR decisions have been associated with negative patient and public perceptions, negative clinicians’ perceptions – don’t like addressing this topic with patients, an uncomfortable conversation and one doctors can chose to avoid.
As a consequence neither side wants to initiate conversations.
They are a source of ethical concern and legal challenge.
It is subject of complaints, litigation, and a stream of negative media reports.
Decisions about DNACPR have taken on practical, emotional and legal significance.
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5. Background Common themes Poor or absent communication
Bad decision-making
Poor or absent documentation
This comprehensive review found many shortcomings in considering, discussing and implementing DNACPR decisions as well as unintended consequences.
The common themes from the review that are behind these problems were …
Poor or absent communication - not considered in a consistent way within and across organisation. Discussion often starts with why CPR not a good idea rather than a more balanced and far reaching discussion about overall goals of care.
Bad decision-making – can be conflated with decisions about end of life car - and mistakenly don’t proceed with other treatment or lines of action like escalation to a more intense care environment like ITU.
And poor or absent documentation leading to lack of clarity within and across teams about what to do when at a crisis point.
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6. Background Court of Appeal 2014 DNACPR decisions
“… presumption in favour of patient involvement...”
These failures were all demonstrated in the Tracey case, which came to the Court of Appeal in One of the key statements in the judgement was that, when a DNACPR decision is considered, there should be a presumption in favour of involving the patient.
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7. How could we do better?
Discuss CPR in the context of broader care plans
Discuss treatment to be given
More frequent (routine) conversations
National documentation
As a consequence of the Warwick event consensus gathered around the need to
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8. ReSPECT was created by…
Following the Warwick meeting 37 stakeholders came together, convened regularly to develop an approach that coule meet needs of different care settings and travel with the patient. Drew on examples of best practice nationally and internationally.
A public consultation attracted over a 1000 responses.

9. What is ReSPECT? ReSPECT – an alternative process
for discussing, making and recording recommendations about future emergency care and treatment, including CPR
ReSPECT – developed by many stakeholders including patients, doctors, nurses and ambulance clinicians, to try to achieve a process that will be adopted nationally
ReSPECT records treatments to be considered
as well as those that are not wanted or would not work
ReSPECT encourages people to plan ahead
for their care and treatment in a future emergency in which they are unable to make decisions
Let’s consider what ReSPECT is
• ReSPECT is not just a form. It’s an alternative process for discussing,
making and recording recommendations about care and
treatment in a future crisis, including
CPR.
• ReSPECT has been developed by many stakeholders, including patients,
doctors, nurses and ambulance clinicians, to try to achieve a process that can be adopted nationally.
• It’s important to remember that ReSPECT focuses on treatments that should be considered for a person, as well
as those that are not wanted or that would not work in their situation.
• The aim is also for ReSPECT to encourage people to plan ahead for their
care and treatment in a future crisis in which they can’t make decisions for themselves.
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10. ReSPECT – what it isn’t! not another DNACPR form
not specifically for end-of-life care
not a substitute for an advance care plan
not an ‘order’
Not just a form. Source of the problems referred to at beginning not solved by a form in either paper or digital form.
Wider applicability than end of life care.
It is not a detailed care plan, but confined to a summary.
And does not reflect a binding decision, it is a recommendation to refer to in the face of an emergency (exception to this is where an advance Decision to refuse treatment been made and then legally binding)
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11. ReSPECT – Aims More conversations between people and clinicians
More planning in advance
Good communication
Good decision-making
Shared decision-making whenever possible
Good documentation
Cross-boundary recognition
Better care
This will inevitably take time, but if we can embrace this approach, it should lead to these conversations between
people and their clinicians occurring more frequently, resulting in more advance plans for people’s care. It
should encourage better communication, better decision making– with shared decision-making whenever possible, good-quality documentation of both decisions and discussions and – if we achieve at least some of these – it should result in
something that we would all aspire to –better care of our patients.
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12. ReSPECT – what’s needed?
A change of culture involving:
health and care professionals
members of the public
What I wish to emphasise at this point is what is needed is it is to work hinges on
as much about a a change of culture on the part of health and care professionals, so that they are much more willing to have conversations with their patients about these topics, and recognise their responsibility to do that and a change
of culture on the part of members of the public, so that they come to expect these conversations as a
routine part of their care and to recognise the importance of planning ahead.
This will not be easy, but the ReSPECT approach offers a step towards achieving this.
Getting the documentation right and mechanisms for transfer of information between teams and sectors are also important and the aim of ensuring that patients receive the right treatments at the right time is one that is universally accepted.
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13. ReSPECT – who is it for? Anyone, but especially people:
▫ with particular healthcare needs
▫ nearing the end of their lives or at risk of cardiac arrest
▫ who want to record their preferences for any reason
ReSPECT is best completed when a person is relatively well, so that their preferences and agreed clinical recommendations are known if a crisis occurs
If someone with no ReSPECT form has an acute illness, consider discussing and completing ReSPECT as soon as possible
Now let’s consider who should be considered for ReSPECT. Anyone who wants to can participate in the ReSPECT process, but it will be most relevant for and led itself to certain conditions and circumstances:
• people who have particular
healthcare needs - perhaps a long-term condition or a severe disability that may deteriorate suddenly
• people who are nearing the end of their lives
• people who are at risk of cardiac arrest but are not terminally ill – this would
include people with acute myocardial infarction, for example
• and others who want to record their preferences for any reason.
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14. ReSPECT – other features
ReSPECT can be used for people of any age
When used for a child or young person must be appropriate parental involvement
ReSPECT can complement other documents such as advance care plans but does not replace them
If a person has a completed ReSPECT form there should be no need for a separate CPR decision form or TEP
Some other features of ReSPECT are
firstly that it can be used for people of
any age, including children. If it is
used for a child or young person, it’s
crucial to ensure appropriate parental
involvement.
ReSPECT does not replace other
documents such as adult or paediatric
advance care plans but it doesn’t
replace them. It simply provides a
summary of those recommendations that
might be needed to guide immediate
decision-making in a crisis.
However, if a person has a completed
ReSPECT form there should be no need
for a separate CPR decision form or
another treatment escalation plan.
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15. Key parts of the process
As a reminder, ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment. The ReSPECT process creates a summary of personalised recommendations for a person’s clinical care in a future emergency. Key parts of the process include:
explore & enhance a shared understanding of their condition
help person to identify priorities for their care and what is important to them
agree & record clinical recommendations
the main focus of treatment
specific types of care and treatment
whether or not to attempt resuscitation
The plan is created through conversations between a person and one or more of the health professionals who are involved with their care.
The plan should stay with the person and be available immediately to health and care professionals faced with making immediate decisions in an emergency in which the person themselves has lost capacity to participate in making those decisions.
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16. Introducing & Using ReSPECT
ReSPECT made available for adoption by health and care communities in February 2017.
Introduced in some localities as part of a 3 year NIHR funded research evaluation
Moving to next phase where health and care communities wishing to adopt ReSPECT offered access to materials needed to plan implementation.
Interested organisations should join the Implementation Network.
Implementation of ReSPECT will be a gradual process, different health communities adopting and implementing using different timeframes, according to local or regional circumstances
Health communities adopting ReSPECT are directly responsible for establishing an implementation group and developing implementation plan (e.g. training, resources, risks, interdependencies and audit).
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17. Where to find out more…
On the ReSPECT process and implementation network
Review the website and materials - specimen ReSPECT form, the FAQs, the Implementation Roadmap and ‘Act and Adopt’ documents
Feedback is welcomed . ReSPECT aims to be a dynamic process that responds to, and develops further from, feedback
BMJ articles accessible via the website: Analysis:  Resuscitation policy should focus on the patient, not the decision Practice Pointer:  Emergency care and resuscitation plans
BMJ Talk Medicine podcast on emergency care plans at end of life
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18. Viv Cummin, Patient Representative, ReSPECT Working Group
A word from patients
“Let's face it - no-one really wants to think about what might happen if they were to become critically ill! But of course the best way to do that is by planning ahead and doing the thinking while there's no crisis to deal with. That way you have time to think clearly, take advice, and share your thoughts and wishes with the people who might have to care for you. The ReSPECT process provides this opportunity in a clear, straightforward way. It will hopefully make it much easier for everyone, both inside and outside the healthcare professions, to make these challenging decisions together.”
Viv Cummin, Patient Representative, ReSPECT Working Group
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