What is ReSPECT?
Recommended Summary Plan for Emergency Care & Treatment (ReSPECT) is a process that creates individual recommendations for a person’s clinical care in emergency situations, including cardiorespiratory arrest. The process involves a conversation that:
- develops a shared understanding of a person’s condition, circumstances and future outlook
- explores the person’s preferences and records the agreed clinical recommendations for their care and realistic treatment in the event of a future emergency in which they cannot make or express decisions at the time.
In Kent and Medway, ReSPECT will replace both TEP (treatment escalation plans) and DNACPR (do not attempt cardiopulmonary resuscitation) forms in a phased transition (see later sections for more details).
Evidence shows that DNACPR decision making is flawed:
- No one likes discussing it
- It’s misunderstood, often mistakenly thought to equate to end of life care
- It can result in a difference in care and appropriate treatments are often withheld
- There’s a variation in approach across organisations with differing forms, expiry dates etc.
Complaints about DNACPR have fallen significantly in organisations where ReSPECT has been adopted. Clinicians are happier discussing a decision about CPR within wider goals of care and focusing on choices of treatments.
This is an opportunity to introduce one process for recording CPR (cardiopulmonary resuscitation) decisions across Kent and Medway and nationally, supported by the Resuscitation Council.
Any person of any age from pre-term to adult, but is especially relevant for people:
- with health needs that may involve a sudden deterioration in their health
- with a life limiting condition, such as advanced organ failure, advanced cancer or frailty
- at risk of sudden events, such as epilepsy or diabetic crisis
- at foreseeable risk of death or sudden cardiorespiratory arrest
- who want to complete the ReSPECT process and plan for other reasons (such as cultural or religious reasons, or a strong wish not to be kept on life support or have artificial feeding etc.).
ReSPECT can apply to any emergency, including those where full recovery is expected.
Like any care plan, it is not legally binding but contains valuable guidance which must not be ignored in decision-making at the time of an emergency. Not every clinical scenario can be predicted and so the preferences/goals of care are the key to allowing a decision to be made in an emergency.
Some people are surprised to find out that DNACPR forms are also not legally binding documents.
In England and Wales, an Advance Decision to Refuse Treatment (ADRT) is legally binding if it is valid and applicable to the circumstances. Details of an ADRT must be included in section 2 of the ReSPECT plan if present, along with details of other relevant advanced care plans and where to find them.
No, ReSPECT incorporates the DNACPR decision at the bottom of the first page so in Kent and Medway we will be moving away from using DNACPR forms. There will be a transition period where some patients will still have DNACPR forms because they have not yet had an opportunity to have a ReSPECT conversation and to complete a ReSPECT plan. DNACPR forms will continue to be effective and do not need to be immediately replaced.
ReSPECT is more than a DNACPR form as it also records patient preferences and guidance for emergency care and treatment. It is likely many patients will have the ‘CPR attempts not recommended’ box signed but having a ReSPECT plan does not necessarily mean that someone is not for CPR attempts.
Both. In Kent and Medway we are adopting ReSPECT as a digital form with a printed copy because of the benefits of being able to share the e-form quickly and easily across organisational boundaries.
ReSPECT will be available as an e-form on the Kent and Medway Care Record (KMCR) and the completed ReSPECT plan will be printed and given to the patient. A how-to video guide for using ReSPECT on KMCR is available here: RESPECT e-form Demonstration on KMCR - YouTube and the user guide is available from joanne.lucas9@nhs.net (not for public sharing due to protected intellectual property).
If a ReSPECT plan is completed in the community without KMCR/internet access a handwritten copy can be created to leave with the person, and a photo taken so the form can be inputted to KMCR when access is available. Local organisational policy should ensure there is a clear process in place for version control and uploading timeframes. Individual organisations should print off hard copies for use by their staff if they need to handwrite a ReSPECT plan.
Any trained clinician involved in the care of the patient can create a ReSPECT plan, where this seems likely to be helpful. It does not have to be the GP, or the hospital doctor, and might be a specialist nurse involved in the patient’s care.
In the community, appropriately trained nurses can complete ReSPECT plans; these do not need to be countersigned by the GP. Other clinicians can review and amend the ReSPECT plan once it has been created.
Sections 4 and 7 of the form must be signed (with the date and time of signing) by the professional who completes, reviews, or amends the ReSPECT plan. If it is not the senior responsible clinician, they should be informed of the plan’s completion, and at the earliest practicable opportunity they should review and endorse the recommendations by adding their signature. Or, if appropriate, consider further discussion and possible revision of the plan. The senior responsible clinician will usually be the person’s GP or consultant. In some situations, such as nurse-led units, a senior nurse may have this role. Please note: A ReSPECT plan that does not have the signature of the senior responsible clinician is no less valid than one that does.
Once a ReSPECT plan is completed by a clinician, doctor or nurse, it is their responsibility to inform the wider health care team.
The minimum level of ‘appropriate training’ required to be able to complete a ReSPECT form is the RCUK ReSPECT app education package (learning.respectprocess.org.uk) and confidence to have ReSPECT conversations. Communication skills training should also be considered to support the use of ReSPECT.
For further details of the ReSPECT Process please see the Kent and Medway Standard Operating Procedure or your local organisational policy:
If a person does not want a ReSPECT plan, then their wishes should be respected. If there is a clear clinical view that a ReSPECT form could be of benefit to them, the reasons for them not wanting this should be carefully explored and documented. Try to avoid using language such as ‘refused.’ Try to offer them further opportunities to discuss this again or to change their mind as and when they are ready to do so.
Where the clinical team think that a particular treatment or intervention should not be initiated in an emergency, all attempts should be made to explain this to the person or their representative including offering a second opinion. A patient cannot demand a treatment that the clinician believes to be inappropriate. If a shared understanding and recommendation cannot be reached the clinician may choose not to complete a ReSPECT plan and should document the reasons in the medical record.
ReSPECT is a summary plan and should contain the brief details and recommendations which would be most helpful in an emergency. Other advance care plans will contain more detailed information to guide a person’s care and treatment in other circumstances. A PCSP is often more about the patient's holistic care and things they would like to change. Some ACPs and PCSPs are very long (more than 20 pages) so can be valuable to guide complex decisions when time allows, but they can be a handicap when a rapid decision is needed.
Treatment Escalations Plans (TEPs) fulfill a similar role to ReSPECT and were implemented in Kent and Medway during the COVID-19 pandemic. However, ReSPECT is nationally recognised and more person centred than TEPs.
Existing TEPs don't need to be replaced, but the ReSPECT process should be considered when the TEP needs to be reviewed with the view of putting a ReSPECT form in place for that person.
TEPs don't necessarily work across organisational boundaries, so although there is no need, you might want to migrate your patients to ReSPECT as soon as possible.
A pdf copy of the form must be emailed to ReSPECT@secamb.nhs.uk including when there any updates and changes to the form, so that SECAmb ambulance clinicians can access the ReSPECT form via IBIS on their tablets. SECAmb are working towards KMCR and will be moving away from IBIS once everyone in the southeast is using a shared care record.
Once the ReSPECT e-form is available on the Kent and Medway Care Record (KMCR) and staff members have completed ReSPECT training (learning.respectprocess.org.uk), clinicians can begin to offer ReSPECT conversations to patients and complete a ReSPECT plan with them. The completed document will be printed, and a copy given to the person to keep with them. Forms printed in black and white are acceptable.
Existing DNACPR forms will continue to be valid and will be recognised by all organisations as before and do not need to be replaced immediately.
Once ReSPECT is adopted patients discharged from acute and community hospitals will have a ReSPECT plan on KMCR if appropriate, not a DNACPR form. The NHS Kent and Medway ReSPECT project team will work with the hospitals to set a timeframe for when this is expected to start.
The ReSPECT process is still important if someone lacks capacity. A capacity test should always be documented in the clinical records for each specific decision. If their capacity is lacking for a specific decision, then the decision must be taken in their best interests
Best interest discussions should ideally include at least one person who knows the individual. Ensure you have consulted a lasting power of attorney for health and welfare, if they have been appointed, and other health or social care practitioners.
An Independent Mental Capacity Advocate (IMCA) is required if the individual has no LPA/family/ friends - to refer, please visit: Independent Mental Capacity Advocates - Kent County Council
Please ensure you are familiar with the Mental Capacity Act requirements: https://www.scie.org.uk/mca/practice/best-interest/
There is no set date for a review or expiry. ReSPECT conversations should take place when a person's health needs or personal circumstances change. If a review is required, the clinician should discuss the goals of care and recommendations and then amend or update the ReSPECT plan ensuring they follow the standard operating procedure.
Significant changes in the patient’s condition, for better or worse, should trigger a review of the form to ensure that they continue to be relevant, but the process of discharging from hospital to a residential or nursing home should not automatically trigger the need for a review.
The ReSPECT form remains valid across all settings and for this reason clinicians should take care that the ReSPECT plan does not use unnecessary jargon and is applicable to a community setting such as the patient’s home or a care home.
It is considered good practice to review the form at regular intervals and update the recommendations as the patient’s wants or clinical condition change. When a patient is discharged from hospital with a new or updated ReSPECT form this should be a prompt to review other care plans to prevent the risk of contradictory care plans.
The review of a form may not require more than a telephone discussion with the care home (for example), but this will require individual consideration of the patient’s situation. Remember that the GP is not the only person who can review a ReSPECT plan.
Care homes residents are not expected to have a ReSPECT plan created straight away. The CQC will not expect this, though there should be an agreed plan for gradual implementation. Care homes should work with their PCN care home team to create ReSPECT plans on KMCR for their residents.
Additionally, some residents will be discharged from hospital with a ReSPECT plan completed or transferred between institutions with one already in place. Other individuals may have one completed when their care is reviewed, so there will be no expectations of overnight implementation. Primary care should also be informed of any patients moving from out of area into a care home within Kent and Medway.
All residents should have been offered a ReSPECT conversation within approximately six months of adoption. The PCN care home team should support this aim, although in some cases it may take longer than this.
The most recent form, whether DNACPR or ReSPECT will be valid. Old forms should be clearly and legibly cancelled. The KMCR keeps a history of all previous versions of the ReSPECT form on the patient’s electronic record.
Visit the ReSPECT Resources from Resuscitation Council UK for resources including patient leaflets, easy read guides and videos.
An individual patient should not have both a DNAR form and a ReSPECT plan. Once a patient has had a ReSPECT conversation and a ReSPECT plan completed their old DNAR form is no longer needed.
Trusts must decide how best to use ReSPECT for their patients and staff. DNACPR forms may continue to be used within the hospital for some time or during the transition period, with a ReSPECT plan used on discharge.
In the hospital a ReSPECT form could be started in an emergency, with more information added once the patient has stabilized. See the scenarios in the ReSPECT e-learning for more information about how ReSPECT may be used in an emergency: ‘A person with unexpected deterioration’ scenario (respectprocess.org.uk).
The CYPACP (child & young persons advanced care plan) collaborative is a national working group of NHS and private sector organisations with the common goal of delivering the best possible care to children and young people with life limiting and life-threatening conditions. They are currently working on a care plan for children and young people. Please go to http://cypacp.uk/ for more information.
ReSPECT will be part of the wider CYPACP which will likely be eight to twelve pages long. The ReSPECT project team is working with the CYPACP collaborative, as well as paediatric clinicians to successfully use ReSPECT in Kent and Medway.
Yes, Resuscitation Council has an audit tool available which will be used across Kent and Medway. Patient satisfaction surveys will also be used led by Healthwatch, as well as looking at individual cases and small samples to review the quality of decision making based on ReSPECT forms and the appropriateness of reviews.
ReSPECT was developed by a national Working Group comprising many professional organisations including Resuscitation Council UK (RCUK), British Medical Association (BMA), Royal College of General Practitioners (RCGP), General Medical Council (GMC), Care Quality Commission (CQC), Royal College of Nursing, and Association of Ambulance Service Chief Executives. There was the opportunity for feedback during the consultation process, and over 1000 responses were received (more than 90% of which were positive). It is intended that the document will be adopted across the UK.