Recommended Summary Plan for Emergency Care and Treatment (ReSPECT)

Policy for use across all providers in Gloucestershire

Date Policy Agreed August 2019

Date Policy to be Reviewed August 2022 Broad Recommendations / Summary

Summary

1Version 4

This document outlines the One Gloucestershire policy covering the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process (including resuscitation recommendations) for all adult individuals/patients. This Policy aims to protect individuals/patients and support staff in making these complex recommendations.

ReSPECT is an approach to discussing, making and recording recommendations about future emergency care and treatment, including cardiopulmonary resuscitation (CPR). ReSPECT focuses on treatments to be considered as well as those that are not wanted or would not work.

When ReSPECT should be considered in all care and treatment environments where the clinician or patient wants to record, in advance, recommendations for emergency care and treatment. Anyone may wish to have a ReSPECT discussion/document priorities but prompts may include all hospital admissions/increasing frailty and long term chronic conditions.

Identification of likely last year of life through a tool such as SPICT may prompt discussions. ReSPECT will remain active across all care settings unless stated otherwise. It can transfer across all settings within Gloucestershire and is designed to be recognised nationally.ReSPECT should be reviewed when clinically appropriate, on patient request, when the patient is transferred from one healthcare institution to another or admitted from home or discharged home.

Who The overall responsibility lies with the Consultant/GP, in their absence a doctor of grade ST3 or above or Advanced Nurse Practitioner (ANP)/ Clinical Nurse Specialist (CNS)/Specialist Practitioners with appropriate training can make a ReSPECT recommendation which includes Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) on grounds of medical futility.

FY2-ST2 grade doctors/Specialist Practitioners can only make a ReSPECT recommendation including DNACPR on medical futility grounds having had discussions with a clinician as identified above. These discussions must be clearly documented in the patient’s medical notes.

If a patient who has capacity asks to document their wishes, including DNACPR, a registered senior healthcare professional who has had training in the assessment of capacity and consent and has had this role delegated by a Consultant/GP can complete the ReSPECT process. If a patient with capacity has strong views over declining treatment, they may prefer to complete an Advance Decision to Refuse Treatment.

Adults and where appropriate their families, should be involved in discussions about emergency care and treatment recommendations unless they indicate that they do not want to be. It must be recognised that all individuals/patients may choose to discuss this at a later date if they change their mind.

A clinician cannot be forced to give treatment that they consider not to be in the best interests of the patient, including an attempt at resuscitation.

Discussions within the healthcare team should aim to achieve consensus about ReSPECT recommendations.

How Following the necessary discussion and decision-making, the process must be documented and recorded on the approved form with all fields completed. To assist dissemination this

2Version 4

decision should be recorded on appropriate electronic patient records/summary care records/discharge summaries etc. and when in hospital, be filed in the front of the patient’s notes.

Individuals/patients who have a completed ReSPECT form may still be considered for CPR attempts, subject to what has been recorded on the appropriate part of the form.

For individuals/patients in hospital, ensure all Healthcare staff are aware a ReSPECT form has been completed, drawing attention to any recommendations made regarding Do Not Attempt Cardiopulmonary Resuscitation (DNACPR). For individuals/patients in community settings, ensure appropriate communication/documentation of the presence of a ReSPECT form e.g. document +/- scan a copy of ReSPECT document into any appropriate Electronic Patient Record (EPR), particularly the summary care record to enable sight in JUYI.

Exceptions If doubt exists over a patient’s resuscitation status – resuscitation should be commenced. In all individuals/patients, clinical judgement can override ReSPECT in favour of treatment if a readily reversible cause for the deterioration has been identified, e.g. choking, blocked tracheostomy tube.

If the clinical/ resuscitation team/paramedics attending a resuscitation call have all the necessary information regarding the individuals/patients clinical status; and feel that continuing resuscitation would not be in the individuals/patients best interests then the attending team can make the decision to stop attempts at CPR.

Recommended Summary Plan for Emergency Care and Treatment (ReSPECT)

1. Purpose / Legal Requirements / Background

3Version 4

1.1 To set out the principles which govern the use of the Recommended Summary Plans for Emergency Care and Treatment (ReSPECT) process across One Gloucestershire.

1.2 This Policy has been written with reference to the latest guidance issued by the British Medical Association (BMA) / Royal College Nursing (RCN) / Resuscitation Council and the recommended standards issued in the Joint Statement from the Royal College of Anaesthetists, the Royal College of Physicians, the Intensive Care Society and the Resuscitation Council (UK). (https://www.resus.org.uk/dnacpr/).

1.3 Emergency treatments including Cardiopulmonary Resuscitation (CPR) can be attempted on any patient who’s cardiac or respiratory functions fail. Failure of these functions may be part of dying and thus emergency treatments and CPR could theoretically be attempted on every individual prior to death. For some individuals/patients there comes a time when death is inevitable, and it is essential to identify individuals/patients approaching a terminal event in their illness in which emergency treatment is not appropriate.

2. The Scope 2.1 This policy applies to all individuals/patients in whom ReSPECT decisions are being

considered. For all those at risk of deterioration or cardiac arrest or who want to have their wishes documented, a conversation regarding treatment options and focus of care should be held and a ReSPECT form should be completed. The aim of the ReSPECT process is to protect individuals/patients and support staff in making complex recommendations and to ensure all decisions/discussions are clearly recorded and communicated across healthcare providers.

2.2 This policy must be made available to individuals/patients on request.

3. General Principles 3.1 ReSPECT addresses treatment planning in relation to emergency, potentially life-

extending treatment, including CPR. It should be considered for those individuals/patients who are at risk of a clinical deterioration that may place their life at risk. These individuals/patients may already have an existing life limiting illness, such as advanced organ failure, or cancer. The scope of ReSPECT can cover other treatments-for example, antimicrobial therapy in those at risk of infection, ventilation in those at risk of respiratory failure or artificial nutrition/hydration in those at risk of aspiration. Additionally, patient wishes may lead to a ReSPECT document being considered, discussed and used, even in the absence of advanced, or indeed any, illness. Use of the SPICT tool may help with identification of individuals/patients who may be in the last year of life. Appendix 2 and/or the prognostic indicator guidance from the EoL Gold Standards framework.

ReSPECT aims to promote more conversations between individuals/patients (and / or their families) with clinicians, leading to shared decision making (when possible), better advanced planning, good communication and documentation and better overall care.

3.2 ReSPECT recommendations must be made on the basis of an individual patient assessment and in consultation with the patient, save in the exceptional circumstance that consultation is likely to cause physical or psychological harm to that patient.

4Version 4

3.3 ReSPECT must be reviewed regularly. A review will be required: • Whenever changes occur in the patient’s condition

• If there is a change in the patient’s expressed wishes

• Whenever the patient is admitted, discharged or transferred from one healthcare provider to another-ideally within 48hrs but recognition this may be longer in home/care home settings. The frequency of review should be determined by the health professional in charge of the patient’s care and will be influenced by the clinical circumstances of the patient. Prior to changing/cancelling the ReSPECT, a discussion should take place with the patient/family and amongst the multidisciplinary team including the Consultant/GP responsible for the patient’s care depending on their location.

3.4 Unless cancelled, ReSPECT covers hospital and community care episodes.

3.5 ReSPECT is not a legally binding document. It does not override clinical judgment in the event of a reversible cause of the patient’s respiratory or cardiac arrest that does not match the circumstances envisaged when the recommendation was made, provided that there is not a valid and applicable Advance Decision to Refuse Treatment (ADRT) expressly refusing such intervention. In an emergency, the presumption should be in favour of CPR if this has a realistic chance of prolonging life. Examples for overriding ReSPECT in favour of treatment include choking, blocked tracheostomy.

3.6 In the event of a patient undergoing general anaesthesia, the ReSPECT form should be acknowledged, reviewed and discussed with the patient and clinical team. A Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision as part of the ReSPECT recommendation should be reviewed in accordance with the Do Not Attempt Resuscitation (DNAR) Decisions in the Perioperative Period (Association of Anaesthetists of Great Britain and Ireland) 2009.

3.7 A ReSPECT should be made in accordance with the requirements of the Human Rights Act 1998, the Mental Capacity Act 2005 and all professional regulatory bodies. Please refer to Gloucestershire’s MCA policy and procedures for each organisation.

3.8 Where there is uncertainty over a ReSPECT (particularly where it relates to CPR) then, in the event of a cardiac arrest, resuscitation should be commenced.

3.9 At the time of making a ReSPECT, staff should discuss treatment options and goals of care (e.g. referral to DCC, HDU, acute/community hospital, administration of antibiotics/dialysis/BiPAP and NEWS2 scoring etc.) which are relevant to the patient. Recommendations limiting other aspects of care must be clearly and explicitly recorded in the medical record and communicated to multi-disciplinary team members.

4. A DNACPR recommendation relates only to the act of CPR (e.g. chest compressions, ventilations, and defibrillation) and does not in itself place any limitations on other aspects of the individuals/patients care. However, the ReSPECT process encourages clinicians to explore other treatments and the goals of care with the patient rather than make decisions about CPR in isolation.

5Version 4

5. Responsibility for ReSPECT: 5.1 The consultant/GP in charge of the patient’s care at the time the ReSPECT is made

carries responsibility for that recommendation until the patient is formally transferred to the care of another consultant or GP, at which point the receiving senior clinician will assume responsibility. The consultant/GP should be prepared to discuss the recommendation for the patient with other health professionals involved in their care.. This is particularly relevant when formulating ReSPECT for outpatients or those being discharged.

5.2 In their absence, doctors of grade ST3 or above or Advanced Nurse Practitioner (ANP)/ Clinical Nurse Specialist (CNS)/Specialist Practitioners, can make a ReSPECT recommendation which includes DNACPR on grounds of medical futility. FY2-ST2 grade doctors/other healthcare professionals can only make a ReSPECT recommendation including DNACPR on medical futility grounds having had discussions with an ST3 grade or above. Each organisation will outline roles and responsibilities given the breadth of staff groups. These discussions must be clearly documented in the patient’s medical notes/electronic care record as appropriate to their care setting at the time..If a patient who has capacity asks to document their advance statements of wishes and/or including any Advance Decisions relating to DNACPR, a registered senior healthcare professional who has had training in the assessment of capacity and consent and has had this role delegated by a consultant/GP can complete the ReSPECT process.When the consultant/GP next reviews the patient they should sign to endorse the ReSPECT recommendations.

5.3 ReSPECT recommendations should be made in partnership and consensus with individuals/patients, the person’s family/people important to them where appropriate, and the clinical multidisciplinary team.

5.4 The importance of teamwork and good communication cannot be over-emphasised. Where care is shared between hospital/community teams and general practice, the relevant professionals should discuss the issue with each other, with members of the health care team and with the individuals/patients and their families as appropriate. A delegated individual should take charge of ensuring that the recommendation is properly recorded and conveyed to all clinical staff involved in the care of that patient.

5.5 Recommendations must be based on reliable, up-to-date clinical guidelines and informed by the discussions had with the patient and relevant family members.

6. Resuscitation recommendations and ReSPECT See decision making framework Appendix 46.1 DNACPR recommendations are usually only appropriate in three settings:

Where attempting CPR will not restore the patient’s cardiac output, the healthcare team must be as certain as it can be that attempting CPR would be futile. This recommendation should be based on clinical assessment of the patient and relevant guidelines.

Burdens that outweigh benefits - where the expected benefit is outweighed by the burden e.g. terminal illness. This assessment can only be made following discussion with the patient (or relatives if the patient lacks capacity or if declining involvement gives permission for the family to be involved).

6Version 4

Patient refusal - where CPR is against the wishes of a patient it may be expressed verbally or in accord with a valid and applicable ADRT. A valid advance decision refusing CPR must be made by someone aged 18 or over, who had capacity at the time the was completed, be in writing, signed, witnessed and state that the named patient refuses any life-sustaining treatment ‘even if life is at risk’.

6. Making a ReSPECT Decision6.1 Communication and good record keeping are central to the safe and effective use of

the ReSPECT policy. 6.2 The Resuscitation Council (UK) / RCN / BMA Guidance Decisions relating to

cardiopulmonary resuscitation (2016) provides general guidance on deciding when and how approaches to individuals/patients and relatives should be made. The circumstances of each patient should be considered and a plan formulated on a case by case basis.

6.3 Discussions around emergency treatments should be undertaken sensitively. Clinicians should be responsive to verbal and non-verbal communication signals from the patient which may indicate the extent to which they wish to be involved in these discussions.

6.4 Discussion within the healthcare team (doctors, nurses, allied health professionals) should aim to achieve consensus about a ReSPECT.

6.5 ReSPECT recommendations should be recorded on the nationally recognised form which should be filed at the front of the patient’s medical notes/uploaded onto electronic patient record while in and inpatient setting.

6.6 In the context of an acute/emergency admission, whilst the ideal is that all sections of the form should be completed and an entry should be made in the medical notes providing the rationale for the decision by documenting all relevant discussions held with the patient and any relevant others – it is recognised that when a first/(new) ReSPECT document completed as part of an acute admission, the focus may need to be on clinical recommendations only with other sections completed as clinical condition allows. In addition, the process of completion may occur over several consultations and therefore the form be added to gradually.

6.7 If a decision is made that an attempt at resuscitation would NOT be recommended i.e. a DNACPR – a yellow sticker should be applied over the ‘Recommended for CPR and Modified CPR’ signatory section. The ‘Not recommended for CPR section is then signed by the clinician. This is unique to Gloucestershire and is designed to aid ease of recognition of a DNACPR recommendation in an emergency BUT forms should always be scrutinised carefully as the form may have come from a different area.

6.8 The clinician responsible for completing the ReSPECT form must record on electronic patient records under the advance directive function the ReSPECT decision including DNACPR. A scanned PDF copy of the ReSPECT document will be saved to this entry by administration or clerical staff as soon as possible or by the end of the next working day. If discharge takes place over a weekend clinical staff must ensure the contents of the ReSPECT form are documented within the discharge summary and ideally, an alert added to EPR(e.g.Trak/SystmOne).

6.9 Nursing staff have a duty to record and maintain up to date nursing records of ReSPECT including resuscitation. Robust systems must be in place to ensure effective communication between shifts and whenever a patient is transferred between clinical areas (e.g. ward to Radiology/MRI or acute to community setting)

6.10Non English speaking individuals/patients and families.For these individuals/patients and their families, to ensure an informed decision can be arrived at an interpreter will be required to ensure their understanding of the situation. It is not good practice to use relatives as interpreters. To obtain interpreters follow local procedures.

7Version 4

6.11Individuals/patients with speech, sight or hearing impairment should have facilities provided to ensure their understanding e.g. easy read leaflet.

7. Storage of the ReSPECT Document 7.1 One of the main challenges with any document such as ReSPECT is ensuring it is

accessible in a time of need. Whilst it can never be possible to absolutely ensure this, a key principle will be the sharing of completion of such a document across healthcare teams and recording of the presence of a document within any electronic alert systems.

7.2 The ReSPECT document is designed to be a patient held document.7.3 Checking for such alerts/documents every time a patient is seen in a new care setting

is also vital. It is only by constantly thinking about this that we will become practised in thinking about ReSPECT and making appropriate use of the document. Appendix 5 – process recording ReSPECT.

7.4 Any changes to the ReSPECT document should lead to a new document being completed and the previous document cancelled with two diagonal lines and the word Cancelled with a date and signature in between the lines.

7.5 When a person is receiving care within a healthcare institution the ReSPECT document stored in the person’s current health record should be the same as the version held by the person.

7.6 The document should not be photocopied for clinical use, BUT may be photocopied for audit or administrative purposes; in this case copies must be crossed through with 2 diagonal lines in black ink and the words “COPY ONLY – NOT FOR CLINICAL USE” should be written clearly between them. A copy must be retained as part of the person’s current health record in that setting, and must be crossed through with 2 diagonal lines in black ink and the words “COPY ONLY – NOT FOR CLINICAL USE” should be written clearly between the lines.

7.7 The ReSPECT document is in time, intended to be a replacement for the many DNACPR and ‘emergency treatment plan’ documents that are currently in use in various healthcare settings.

7.8 On the date of ‘go-live’ it is accepted that if a patient has a yellow DNACPR/advance care planning document or Unwell Patient/Treatment escalation form if they are in acute or community hospitals – these will remain valid and applicable but from this date, no more of these documents will be newly completed and the ReSPECT document will become the form of recording. It is recognised that for a period of time, there will be multiple forms in circulation and each organisation will put in place support to try and minimise associated risk. Each organisation will provide clear guidance for their staff.

7.9 In the event that a person dies, a copy of the most recent ReSPECT document should be present in or added to the person’s current health record.

8. Essential aspects of decision-making 8.1 Each case involves an individual patient and their family with his or her own particular

circumstances and it is important to ensure that any recommendations (regarding ReSPECT) are based on these.

8.2 Decisions made not to attempt resuscitate in a particular patient should ideally be made in advance, as part of the overall care planning for that patient and discussed with the family if appropriate.

8.3 A recommendation not to attempt resuscitation applies only to CPR. It must be made clear to the patient and the health care team that it does not imply "non-treatment" and that all other appropriate treatment and care will continue to be considered and offered.

8.4 Once made, all recommendations must be communicated effectively to the relevant health professionals.

8Version 4

9. Implications for Treatment 9.1 ReSPECT focuses on treatments to be considered as well as those that are not

wanted or would not work. 9.2 Consensus amongst all those involved in the ReSPECT process and subsequent

recommendation is the preferred aim. If consensus cannot be reached, a clear note of the reasons for the disagreement and the individual or individuals expressing the disagreement should be made. Ultimately, the responsibility to complete the ReSPECT rests with the consultant /GP in charge of the patient's care.

9.3 Where the clinical recommendation is challenged or an objection is raised about the ReSPECT by a patient, every effort should be made to reach a resolution through sensitive discussions. If an agreement cannot be reached a second opinion and or legal review may be necessary.

10. Reviews and Revocation 10.1A ReSPECT should be reviewed on transfer of care, in response to any change in

the patient’s overall health status or their expressed wishes. The frequency of the reviews should be determined on a case by case basis but generally, a ReSPECT recommendation will remain effective unless cancelled.

10.2When a ReSPECT is cancelled the form should be marked through with two parallel lines and the word “cancelled” written clearly between the lines. The date, time, name and grade of person revoking the ReSPECT should be recorded on the form. The form should be immediately removed and filed in the correspondence section of the medical notes or where electronic patient records are in use, the form crossed through and uploaded onto the system. Amended ReSPECT forms must not be destroyed as they are an important record of discussions and decisions.Electronic patient records must be updated in a timely fashion with any changes to ReSPECT documents.A note fully recording the reasons for this change in recommendation must be made in the patient’s medical notes.

10.3At all times, the caring team/multi-disciplinary team should be made aware immediately when a change to a ReSPECT document is made. The responsibility for this lies with the Clinician amending the document.

11. Individuals/patients with capacity 11.1The Court of Appeal's decision in R (Tracey) v Cambridge University Hospitals NHS

Foundation Trust and others, makes it clear that the patient (and where requested by the patient, the patient's relatives) should be involved in discussions about resuscitation.

11.2 Failure to consult with the patient may constitute a breach of their rights under Article 8 European Convention of Human Rights (ECHR). A ReSPECT should be completed and inserted in a patient's notes after consultation with that patient. Only in exceptional circumstances where the treating clinician considers "the patient will be distressed during consultation and that the distress may cause harm" will it be reasonable not to discuss a patient's resuscitation status / plan of care with them.

11.3Harm can be psychological or physical. Distress alone would not be sufficient grounds not to discuss ReSPECT with the patient/family. A clinical view that CPR or medical treatment is futile is not a sufficient reason not to inform the patient/family.

11.4In the rare circumstances where a clinician has sufficient grounds to believe discussion with a patient about their resuscitation status would cause that patient harm, that clinician must clearly record the reasons for this in the medical notes. Reasons must be robust and health professionals must be able to justify these.

11.5If a patient indicates that they do not wish to discuss emergency treatments and resuscitation, this instruction should be respected. Where a ReSPECT is made and there has been no discussion with the patient because they have indicated a desire to

9Version 4

avoid such a discussion, this must be documented on the form and in the health records, with reasons given.

11.6If a patient with capacity refuses emergency treatments (including CPR) healthcare professionals must comply with their decision and document it in the medical records including details of the discussion & advice given.

11.7Refusal by a patient to allow information to be disclosed to their family and/or friends should be clearly documented and must be respected.

12. The patient who may lack capacity: 12.1Where there is a question about a patient's capacity to be involved in discussions

about emergency treatments, an assessment of that patient's mental capacity must be carried out in accordance with the test set out in the Mental Capacity Act 2005. The starting point when undertaking any capacity assessment is a presumption of capacity. The assessment must be time and decision specific (refer to individual organisational guidance on decision making in individuals/patients that lack capacity).

12.2The outcome of a mental capacity assessment must be recorded on the ReSPECT form and the relevant Mental Capacity Assessment documentation completed within each organisation’s relevant recording mechanism for significant decisions,

12.3In individuals/patients who lack capacity there is a legal obligation to consult with relatives/friends/advocate (such as an Independent Mental Capacity Advocate IMCA), when considering a DNACPR recommendation (Winspear V Sunderland NHS Trust). This might mean delaying a DNACPR recommendation until reasonable and practical steps have been taken to consult the relatives. Such steps may include telephoning at night, which whilst that might be less convenient or desirable than a meeting in office hours, does not mean it is not practicable. In the case of a rapidly evolving clinical scenario when decision making needs to proceed before relatives can be contacted, the following should be documented in the case notes: (1) what attempts have been made to contact relatives, (2) the reasons why the DNACPR/treatment plan recommendation has been made without their consultation and (3) clear instruction that they are informed as soon practically possible.

12.4If individuals/patients lack capacity and have a Power of Attorney for Health (POA) or legal guardian, this person must be consulted about DNACPR decisions.

13. If agreement cannot be reached 13.1Whilst clinicians cannot be required to give medical treatment contrary to their clinical

judgment, and a patient cannot demand treatment, it is unwise to make a ReSPECT recommendation before these conflicts are resolved.

13.2In the event that the clinical team and the patient/ POA are unable to resolve these conflicts a second opinion from a consultant/GP colleague must be sought. If this fails to lead to resolution, then advice from the organisation’s legal team and/or safeguarding team should be sought. Out of hours call the relevant support for respective organisations such as site team/on call manager.

14. ReSPECT in Individuals/Patients Requiring Off Site Transfer and Discharge 14.1Prior to any transfer, the circumstances behind the ReSPECT should be reviewed.

The receiving team in the acute trust or community e.g. GP/ community nursing team/hospice/care home should be made aware of the treatment plans on discharge/transfer between settings.

14.2If the reasons for the ReSPECT remain valid and the patient is considered at risk of deteriorating on route then the ReSPECT should remain active during the transfer. The transfer team must be made aware prior to transfer.

14.3When arranging an ambulance to transfer a patient with a ReSPECT: • Contact the respective ambulance control and state that a ReSPECT is in

place and whether resuscitation or other emergency treatments should not be

10Version 4

attempted by the ambulance crew in the event of deterioration. Advise the patient (and relatives if appropriate) that the ReSPECT will remain in place during the transfer. Record this in the patient’s medical record.

For hospitals;• Ensure there is a copy of the ReSPECT document in medical notes or a copy

is scanned into EPR where appropriate.• Ensure the GP, community nursing team, nursing home, respite care or other

hospital is aware of the ReSPECT recommendation. This will be done through the immediate discharge summary. The original form accompanies the patient.

• For community teams; Ensure there is a copy of the ReSPECT document in medical notes or a copy is scanned into EPR where appropriate.

• Ensure the original ReSPECT form accompanies the person to hospital/other care settings where relevant and that the transfer team and hospital is aware of the ReSPECT recommendation.

15. Individuals/patients admitted with existing decisions 15.1DNACPR recommendations and ReSPECT can only be effective across healthcare

settings if it is shared without delay, with relevant healthcare professionals, whose decisions it is intended to inform.

15.2When a patient attends hospital with an active DNACPR form or ReSPECT it should be reviewed with the patient. The nature of any review of ReSPECT will depend on the particular clinical circumstances of the patient. It may not be necessary to review the content of the document with the patient or those close to them, if sufficient information has been communicated. This will be a matter of clinical judgement for the healthcare professional with overall clinical responsibility for the patient, and other members of the healthcare team.

15.3The outcome of the review should be recorded on a ReSPECT form (either by completing a new form or endorsing section 9 on the existing ReSPECT form). This MUST be completed before transfer from the admitting clinical area.

15.4Any old forms must be clearly cancelled and filed at the back of the medical notes or scanned into EPR as detailed in 9.2.

15.5Any patient attending for care in settings within Gloucestershire with an active DNACPR proforma from another region, should have this decision reviewed at the point of care being required or clinical teams being made aware of such a document e.g. GP when patient registers. If a patient with a reviewed DNACPR proforma has a cardiac arrest this will be honoured. The transfer of this decision to a ReSPECT form should be made as soon as practically possible.

16. Individuals/patients with planned frequent re-admission for treatment with a ReSPECT recommendation e.g. renal dialysis

16.1Individuals/patients receiving regular day case admission for treatment may be exempt from a clinical review of ReSPECT on each admission unless there are clinical changes or the patient wishes to re-discuss.

16.2Give the original ReSPECT form to the patient when discharged to take with them. 16.3If the patient has an acute admission the recommendation must be reviewed by the

admitting physician and, if appropriate, endorsed or a new form completed.

17. Training 17.1ReSPECT will be covered in all face to face training delivered by each organisation’s

training procedures for Resuscitation 17.2All staff involved with the ReSPECT process should complete the ReSPECT e-

learning training package on https://www.respectprocess.org.uk/. The CCG will also develop a face-to-face session which will be delivered by champions to their local

11Version 4

teams. There will be a version which includes completion of the document for those who are actively completing documents/having discussions and an awareness session for those who may come across/need to use the form.

17.3Staff who require training on Mental Capacity and Consent can access e-learning and face to face training available via their own organisations and/or Gloucestershire County Council

https://www.gloucestershire.gov.uk/health-and-social-care/training-for-health-and-social-care-professionals/multi-agency-training/mental-capacity-act-2005-deprivation-of-liberty-safeguards-training/ 18. Process for monitoring compliance.

18.1Each organisation will monitor compliance and audit the ReSPECT process. This will be presented to their governance meeting and a report submitted to the Operational Quality Committee or organisational equivalent on a quarterly basis, along with the EOLC CPG.

18.2ReSPECT will be audited by the Resuscitation Department or agreed department/team on a quarterly basis. The results will be fed back to the Resuscitation and Deteriorating Patient Committee or agreed Committee and the organisational governance teams. Generalised learning will be disseminated as required.

18.3The Resuscitation Department or agreed department/team will undertake additional spot check audits as required

19. Version control of ReSPECT document19.1 As a nationally produced document, One Gloucestershire are not in control of

release of new versions. As such, where a new version is released, the ReSPECT Implementation Group will review the changes made:

If no significant changes, the ReSPECT Implementation Goup will inform organisations of the new version and update the printers. Educational resources will be updated accordingly.

If changes deemed to be significant, the ReSPECT Implementation Group will arrange a meeting to discuss and agree how to proceed.

12Version 4

Glossary

Advance Care Plan (ACP)

An Advance Care Plan is a structured documented discussion with individuals/patients and their families or carers about their wishes and thoughts for the future. It is a means of improving care for people, usually those nearing the end of life, and of enabling better planning and provision of care, to help them live and die in the place and the manner of their choosing. An ACP is likely to contain information about personal preferences (e.g. place of care preferences, funeral plans, understanding prognosis). An advance care plan is not a legally binding document but may contain an advance decision to refuse treatment (ADRT) which if valid and applicable is legally binding.

Advance Decision to Refuse Treatment (ADRT)

An advance decision (sometimes known as an advance decision to refuse treatment, an ADRT, or a living will) is a decision you can make now to refuse a specific type of treatment at some time in the future.It lets your family, carers and health professionals know your wishes about refusing treatment if you're unable to make or communicate those decisions yourself.The treatments you're deciding to refuse must all be named in the advance decision.You may want to refuse a treatment in some situations, but not others. If this is the case, you need to be clear about all the circumstances in which you want to refuse this treatment.Deciding to refuse a treatment isn't the same as asking someone to end your life or help you end your life.To ensure it is valid and applicable, the document must be written formally and clearly without ambiguity. It should be signed and witnessed with regular reviews and shared with appropriate individuals involved in your care such as GP/hospital practitioners and be held in an easily accessible place in your home/through a medi-alert or such like.

Capacity Capacity means the ability to make and express a decision in relation to a particular matter. To have capacity a person must be able to understand the information relevant to the decision, to retain that information, to use or weigh that information as part of the process of making the decision and to communicate that decision (whether by talking, using sign language or any other means). If their mind is impaired or disturbed in some way, making and communicating decisions may not be possible. A person may lack capacity temporarily or permanently. However, a person should be assumed to have capacity for a decision unless or until it has been shown that they do not.

Cardiopulmonary Resuscitation (CPR)

Cardiopulmonary Resuscitation includes all the procedures, from basic first aid to advanced medical interventions, that can be used to try to restore the circulation and breathing in someone whose heart and breathing have stopped. The initial procedures usually include repeated, vigorous compression of the chest, and blowing air or oxygen into the lungs to try to achieve some circulation and breathing until an attempt can be made to restart the heart with an electric shock (defibrillation) or other intervention.

Department of Critical Care (DCC)

Department of Critical Care may also be referred to as Intensive Care Unit (ICU) or Intensive Therapy Unit (ITU). This is the area in a

13Version 4

hospital that provides sophisticated monitoring and equipment to assess and support the function of a critically ill patient’s vital organs, such as the lungs or kidneys or heart and circulation (e.g. a ventilator to help with breathing) until, whenever possible, they recover.

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)

Do Not Attempt Cardiopulmonary Resuscitation decisions have also been called DNR, DNAR or ‘Not for Resuscitation’ (NFR) decisions or ‘orders’. They refer to decisions made and recorded to recommend that CPR is not attempted on a person should they suffer cardiac arrest or die. The purpose of a DNACPR decision is to provide immediate guidance to health or care professionals that CPR would not be wanted by the person, or would not work or be of overall benefit to that person. This tries to ensure that a person who does not want an attempt at CPR or would not benefit from it is not subjected to an attempt at CPR and deprived of a dignified death or, worse still harmed by it.

Lasting Power of Attorney for Health and Welfare

LPA can be given only by people aged 18 years and above. A person given this power under the Mental Capacity Act 2005, has the power and responsibility to make certain decisions on behalf of a person (the donor) if they have lost capacity to make or express those decisions. Only if an LPA gives decision-making power relating to ‘health and welfare’ can the attorney make decisions about a person’s care and treatment. The attorney can make decisions about life-sustaining treatment such as CPR only if the LPA document states this specifically. In order to be valid, an LPA must have been registered with the Office of the Public Guardian.

Mental Capacity Act (MCA)

The Mental Capacity Act (MCA) is legislation designed to protect and empower people who may lack the mental capacity to make their own decisions about their care and treatment. It applies to people aged 16 and over. It covers decisions about day-to-day things like what to wear or what to buy for the weekly shop, or serious life-changing decisions like whether to move into a care home or have major surgery.

Recommended Summary Plan for Emergency Care and Treatment

ReSPECT is the first nationwide approach to discussing and agreeing care and treatment recommendations to guide decision-making in the event of an emergency in which the person has lost capacity to make or express choices. This process can be used by individuals/patients and people of all ages.

Resuscitation Resuscitation is general term used to describe various emergency treatments to correct life-threatening physiological disorders in a critically ill person. For example, ‘fluid resuscitation’ is rapid delivery of fluid into the bloodstream of a person who is critically fluid-depleted. Rapid blood transfusion for someone with severe bleeding is another example. Cardiopulmonary resuscitation (CPR) is sometimes referred to as ‘resuscitation’ but is a specific type of emergency treatment that is used to try to restart the heart and breathing.

Supportive & Palliative Care Indicators Tool (SPICT)

The SPICT™ is used to help us identify people at risk of deteriorating and dying with one or multiple advanced conditions for holistic, palliative care needs assessment and care planning. It is a one sided tool and is available on G-Care/GHNHSFT webpages. It can be used in MDT/GSF/Board Round discussions to help identify where a ReSPECT discussion may be helpful. Appendix 4.

14Version 4

References

Advance Decision to Refuse Treatment, a guide for health and social care professionals. London: Department of Health.

British Medical Association, (2000). The impact of the Human Rights Act 1998 on medical decision-making. London, BMA Books.

British Medical Association, (2001). Withholding or withdrawing life-prolonging medical treatment. 2nd ed. London, BMA Books.

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Integrated Adult Policy NHS Scotland 2010.

GMC Treatment and Care Towards the end of life: good practice in decision making 2010.

Human Rights Act. (1998) London: Crown Copyright. www.opsi.gov.uk/acts/acts1998/ukpga_19980042_en_1.

Mental Capacity Act. (2005) London: Crown Copyright. www.opsi.gov.uk/acts/acts2005/ukpga_20050009_en_1.

ReSPECT: Recommended Summary Plan for Emergency Care and Treatment website available at https://www.respectprocess.org.uk.

Resuscitation Council UK (2016) Decisions relating to cardiopulmonary resuscitation: Guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing (previously known as the ‘Joint Statement’) 3rd edition (1st revision) https://www.resus.org.uk/dnacpr/decisions-relating-to-cpr/.

The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT): A policy to support its use. NHS London Strategic Clinical Networks April 2017.

Tracey v Cambridge University Hospitals NHS Foundation Trust and others [2014] EWCA Civ 33.

Unified Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Adult Policy NHS South Central 2010.

Winspear v City Hospitals Sunderland NHS Foundation Trust [2015] EWHC 3250 (QB)

Appendix 1 - ReSPECT form

15Version 4

16Version 4

17Version 4

Appendix 2 – Quick guide for clinicians

18Version 4

A yellow DNACPR sticker has been used successfully in Gloucestershire for a number of years, the plan is to retain a yellow sticker which can be stuck on the ReSPECT form covering ONLY the Recommended for CPR or modified CPR signature sections.

19Version 4

Appendix 3 - Supportive & Palliative Care Indicators Tool (SPICT)

20Version 4

21Version 4

22Version 4

Appendix 5 – Roles and Responsibilities for recording and use of ReSPECT document across Gloucestershire.

Identification of poor prognosis/possible last year of life/patient requesting discussion about their priorities

SPICT Tool Clinical decline Query prompted from primary care with possible discussion with secondary care colleagues

for specific ceilings of care Recommendation from secondary care via letter/discharge summary to primary care with

clarity over secondary care focused ceilings of medical management

Once value of/need for ReSPECT discussion is identifiedBegin discussions, document any discussion held. If appropriate begin completion of ReSPECT tool.Can be completed in stages depending on wishes of individualSecondary/primary care to liaise over ceilings of care to inform ReSPECT discussion

Individuals/patients in hospital: patient discharged Facilitate discussion if appropriate prior to discharge and complete form for patient to be

discharged with. Telephone GP and outline discussions held and any need for further discussions. Ensure any secondary care interventions which would not be appropriate e.g. NIPPV, dialysis

have been clarified. Form should be photocopied with a copy filed in medical notes-clearly marked as copy across

the front “COPY ONLY – NOT FOR CLINICAL USE”, copy sent attached to discharge summary and original should be held by patient – ensure patient is aware they should carry this with them especially to any hospital attendances.

Where possible, contact Jeanette Welsh in A&E to facilitate a patient first alert being added to Trak which will highlight the presence of a ReSPECT form.

Individuals/patients in community Ensure completion of a ReSPECT form is documented on Summary Care Record. Ideally record location of the document e.g. message in a bottle. Original form to be held by patient – ensure patient is aware they should carry this with them

especially to any hospital attendances. Log an appropriate review time on your system to allow a prompt for this to occur. Ensure summary care record is updated to allow system wide access to presence of

ReSPECT form.

All clinicians Always review SCR which is populated by GP notes hence, GP’s see this information without

needing to log into SCR.

All individuals/patients Ensure that you have your ReSPECT form in a readily accessible place. Ideally, carry it with

you and/or make sure those important to you know where it can be found. It is sensible to store in one place in your home and that your family are aware of where it is. For any hospital attendance, please try and ensure the form comes with you.

23Version 4