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Welcome to the ReSPECT educational materials. This web app has been designed to help you understand the ReSPECT process. What it is, who it’s for and how to use it in your role as a healthcare professional.
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What is ?

Learning objectives – In this module you will learn:

  • What the ReSPECT process is
  • The unique aspects of ReSPECT
  • What may be recorded on a ReSPECT form
  • How ReSPECT relates to what currently exists and how it is different

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INTRODUCTION

Introduction

ReSPECT is a process that creates personalised recommendations for a person’s clinical care in a future emergency in which they are unable to make or express choices. It provides healthcare professionals responding to that emergency with a summary of recommendations to help them to make immediate decisions about that person’s care and treatment.

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ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment and it works like this:

ReSPECT starts with someone who may benefit from or want to participate in the ReSPECT process. A two-way discussion then takes place between the person and the healthcare professional to enable their current and future state of health to be discussed and their priorities of care to be voiced.

The wishes and recommendations are documented on a ReSPECT form by the healthcare professional.

The form is kept by the person and should travel with them.

The plan should be reviewed and can be modified whenever the person’s circumstances or condition changes, or if they want to reconsider the recommendations.

[0:42] In current UK practice, there are many different do not attempt CPR and treatment escalation plan forms. Some are specific to hospital trusts and local communities and they are usually clinician-led. ReSPECT creates a unified nationally recognised process that supports shared decision-making between a person and their healthcare professionals in making anticipatory recommendations about emergency care and potentially life-sustaining treatments, including CPR. ReSPECT is complementary to any wider process of advance or anticipatory care planning.

[1:16] ReSPECT is a different kind of emergency planning process because:

ReSPECT is ‘proactive’ and not ‘reactive’

The recommendations are created through conversations between a person and their healthcare professional when they are well enough to make these decisions for a future emergency in which they are unable to make or express choices. The process encourages more people to make plans, even those who are currently well.

ReSPECT is personalised

The process has been designed to be person-facing, including parts of the form which seek interaction with the person to record their priorities of care. It focuses on what is important to that person and not only on clinical recommendations.

ReSPECT involves more than just the person

Those close to the person, such as family and/or other representatives, can be involved in the process and should be consulted if the person cannot contribute to the conversation.

The multidisciplinary healthcare team can provide an agreed assessment of the person’s health condition and treatment options.

Involving others in the discussion enables them to hear the person’s wishes first-hand and understand the basis for the recommendations recorded.

ReSPECT is about more than just a CPR decision

The process considers broad plans for a person’s emergency care and treatment, identifying care and treatments that could help them achieve their goals of care, treatments they may not want or that may not work for them. These may include being admitted to hospital in an emergency, or being admitted to intensive care. See the ‘Further Information’ section for examples of some other treatments that may be considered.

ReSPECT applies nationally and in all settings

Whereas some current DNACPR and treatment escalation plan forms are only applicable within a certain organisation or community, the ReSPECT process is applicable anywhere in the UK.

The form accompanies the person wherever they are and go, such as home, the Emergency Department, hospital wards, care home, hospice and when using an ambulance or other transport services.

Once the recommendations are recorded they travel with the person and can be updated when necessary.

ReSPECT has been developed by national experts and members of the public

ReSPECT has been developed by a Working Group of over 30 individuals representing the public and a number of professional organisations from a range of care settings and clinical specialties.


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What is ReSPECT?

  • ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment
  • ReSPECT is different from many current DNACPR schemes and treatment escalation plans because:
    • ReSPECT is proactive and not reactive.
    • ReSPECT is personalised.
    • ReSPECT involves more than just the person.
    • ReSPECT is about much more than CPR decisions.
    • ReSPECT applies nationally and in all settings.
    • ReSPECT has been developed by national experts and members of the public.

The key stages of the ReSPECT process are:

1. Understand – To establish a shared understanding of the person’s state of health and medical conditions, and what they might reasonably expect in terms of progressive deterioration, abrupt health crises and longevity.

2. Set goals – To establish what is important to the person, and what they see as the main focus for their care and treatment – balanced between sustaining life and maximising comfort – this allows people to agree their goals of care.

3. Plan – To discuss the treatments that should be considered for a person as well as treatments which they may not want or that may not help them. The recommendations are recorded on a ReSPECT form.

And… though ReSPECT is not legally binding, the recommendations made must be considered when making decisions about the person’s care and treatment and draw attention to any other legally binding documents they may have.

A change of culture is needed to think about emergency care planning in this way, which will take time to embed among the public and among professionals.

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FURTHER READING

Professional insight

“The ReSPECT process is all about thinking ahead with patients about realistic care options in a truly person-centred way. Ultimately the process aims to help people understand the care and treatment options that may be available to them in a medical emergency and enables them to make health professionals aware of their preferences”

Dr Juliet Spiller, Co-Chair of the ReSPECT Working Group & Consultant in Palliative care at Marie Curie Hospices, Edinburgh (website)

“ReSPECT works beautifully alongside the advance care planning work that’s gone on across the country – and there are a number of protocols and forms in use at the moment. The Children and Young Person’s Advance Care Plan (CYPACP) is one of the most widely used forms; and the ReSPECT process and form are complementary to that. ReSPECT presents the key emergency information that may be required in an Emergency Department, or wherever the child or young person first presents, without wading through what can be a very complex document.”

Dr Peter-Marc Fortune, Co-Chair of the ReSPECT Working Group & Consultant Paediatrician

What recommendations can be included on the form?

Some recommendations for care and treatment, that may be considered when having a conversation, and completing a ReSPECT form include:

  • Admission to hospital from the community.
  • Having intravenous antibiotics for a life-threatening infection.
  • Urgent interventions, such as adrenaline for anaphylaxis, seizure control treatment and steroids in Addisonian crisis.
  • Receiving organ support, such as renal dialysis or ventilation.
  • Having blood products.
  • Having an operation.
  • Admission to an intensive care unit (ICU) or high-dependency unit (HDU).

Consider listing those things that are recommended initially, followed by those that are not recommended.

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How ReSPECT fits in with existing documents

What happens to DNACPR forms or treatment escalation plans (TEPs) that are already in existence?

Existing DNACPR forms and TEPs will continue to be effective and do not need to be replaced immediately. When healthcare communities implement the ReSPECT process there must be a robust plan to ensure that existing DNACPR forms or TEPs remain valid for a substantial period of overlap. ReSPECT is not a replacement for a DNACPR form: the aim is to promote recording an emergency care plan by many more people, including many whose ReSPECT forms will recommend active treatment, including attempted CPR if it is required.

What is the difference between ReSPECT and an Advance Decision to Refuse Treatment (ADRT)?

An ADRT is a legal document that people in England & Wales can complete to refuse treatment that they do not want to receive. If it is completed according to the Mental Capacity Act 2005 it is legally binding on anyone who knows about it and who can be confident that it is valid and applicable to the situation that they are dealing with. A ReSPECT form is not legally binding and focuses only on making recommendations about care and treatment that might be considered in an emergency.

A ReSPECT form can be used to draw attention to the presence of an ADRT and should contain relevant aspects within the summary recommendations for treatment and care.

What is the difference between ReSPECT and an Advance or Anticipatory Care Plan (ACP)?

A ReSPECT form is a very specific type of ACP that summarises the emergency care aspect of a wider Advance or Anticipatory Care planning process. ReSPECT records that information so as to make it accessible rapidly to professionals who need to make immediate decisions about care and treatment in a crisis.

An ACP is made with people who are able and willing to think ahead to a time in their illness when they may be unable to express their preferences. An ACP document is usually longer and more detailed than ReSPECT. It is not restricted to planning for an emergency, and is likely to contain information about preferences such as self-management plans, place of care preferences, funeral plans, understanding of prognosis, details of financial and welfare power of attorney.

ACP and ReSPECT are entirely complementary. They may be developed together, from the same conversations, or development of one may prompt people to discuss the other.

What is the difference between ReSPECT and an end-of-life care plan?

Use of and potential benefit from the ReSPECT process is not restricted to people with life-limiting illnesses or those in need of end-of-life care. End-of-life care plans record a person’s individual care and treatment needs as they approach the end of their life, and are not limited to recommendations for use in an emergency.

For people approaching the end of life, the two plans can be complementary. Care must be taken to ensure that both types of plan address the specific needs of each individual.

What if a child or young person already has an advance care plan (like a CYPACP that also has information about their wishes)?Both documents work together, hand in hand. The ReSPECT form contains only a summary of recommendations to help clinicians to make an immediate decision about a child’s treatment in a crisis. Their advance care plan will have more detailed information to guide their care and treatment in other circumstances. The process of advance care planning provides an opportunity to discuss also the relevant elements of a child’s ReSPECT form, allowing the two documents to be completed together.

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Practicalities of the form

Can the form be printed in black and white?

We recommend that the ReSPECT form is printed in colour, because that makes it easy to identify and locate in an emergency. If the form is printed in black and white, there is a greater chance that it will not be found and that immediate decisions will be made that do not consider the person’s previously expressed wishes and the agreed clinical recommendations. However, the colour of the form does not invalidate a properly followed ReSPECT process, or the preferences and clinical recommendations recorded on a form that has not been printed in the recommended colour format.

Can the form be photocopied? 

We recommend that the ReSPECT form is not photocopied for clinical use, but may be photocopied for audit or administrative purposes and labelled clearly “COPY ONLY – NOT FOR CLINICAL USE”.

This is to try to avoid a situation where an original ReSPECT form has been cancelled and replaced because of changed circumstances, wishes or recommendations, but a copy of a previous version has not been cancelled or destroyed, and is used to guide decision-making as if it were the current version.

Can the clinical details on the ReSPECT form be completed automatically from the electronic patient record?

No. At present the form can be printed on paper and completed by hand or used as a fillable pdf, which can then be printed so that the person can keep it with them.

Is there a plan to digitise the form?

The ReSPECT process has been designed initially as a paper-based form that remains with the person. With the development of shared record systems across local health and social care communities, the benefits of sharing a ReSPECT form electronically and being able to view and update it from different care settings should improve the ability to share current and accurate information rapidly, which is particularly important in urgent and emergency care situations.

A digital version of ReSPECT, which can be made available across care settings, including access by both 111 and the ambulance service, as well as to the person themselves, is currently being developed. Where electronic end-of-life care planning systems already exist, the ReSPECT form should run alongside these, or be integrated with them.

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Why was the ReSPECT process created?

ReSPECT has been developed by over 30 individuals representing both public and professional organisations from across the health sector, including service users and statutory organisations.

The ReSPECT process and form were developed iteratively over a period of two years. The project included public consultation, patient focus groups and usability testing, and was informed by best practice in the UK and internationally. The resulting process and form were designed to:

  • be acceptable to patients, those important to patients, health professionals, carers and other members of the public.
  • be underpinned by a good decision-making process.
  • promote good decision-making.
  • promote dialogue between individuals and clinicians.
  • be used across all care settings.
  • be used for individuals of all ages.
  • use evidence and experience from other successful initiatives.
  • consider decisions about CPR within overall goals of care.

ReSPECT was created by representatives of the public and of:

  •      Resuscitation Council (UK)
  •      Royal College of Nursing
  •      British Medical Association
  •      Care Quality Commission
  •      General Medical Council
  •      Association of Ambulance Chief Executives
  •      NHS Scotland
  •      Royal College of Anaesthetists
  •      Royal College of Emergency Medicine
  •      Royal College of Physicians
  •      Royal College of General Practitioners
  •      Royal College of Surgeons Edinburgh
  •      Professional Records Standards Body
  •      Faculty of Intensive Care Medicine
  •      Intensive Care Society
  •      Association for Palliative Medicine
  •      Paediatric Intensive Care Society
  •      Child and Young Person’s Advance Care Plan Collaborative
  •      Joint Royal Colleges Ambulance Liaison Committee
  •      Marie Curie
  •      Macmillan Cancer Support
  •      Mencap
  •      Cambridge University Hospitals
  •      University of Southampton
  •      Warwick Clinical Trials Unit
  •      UCLPartners
  •      Wellcome Trust
  •      Helix Centre
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Law and ethics

“As a lawyer who spends a lot of time thinking about how the mental capacity act interacts with clinical practice, ReSPECT seems to be absolutely invaluable because of what it is allowing people to do. It is moving away from thinking solely about do not resuscitate notices, into thinking about a much more holistic picture about what people want and what they don’t want when it comes to treatment. The more we can make that conversation part of routine clinical practice the better.”

Alex Ruck Keene, practising barrister, writer and educator specialising in mental capacity law

The ReSPECT form is not legally binding. The ReSPECT recommendations are designed to guide immediate decision-making by health and care professionals who respond to the person in a crisis, and who must have valid reasons for overriding the recommendations on a ReSPECT form.

The ethical and legal principles that underpin the guidance in ‘Decisions relating to cardiopulmonary resuscitation’ by the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing are valid also for the ReSPECT process.

 

Will the form be valid in all 4 nations as they have different capacity laws?

ReSPECT is a nationally available process and form. England and Wales have the same capacity law. When ReSPECT is adopted in Scotland some limited changes of wording may be made, but the ReSPECT process and basic structure of the form will remain the same and it is expected that a form completed in Scotland would be recognised and respected in England or Wales, and vice versa. New capacity legislation for Northern Ireland was passed in 2016 and has many provisions in common with the law in England and Wales, but has not yet been implemented.

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Quiz Me Next Module FAQs
A person with unexpected deterioration

SCENARIO INTRO

RM is a 22-year-old student who is involved in a road accident. He is found unconscious and brought to the nearest hospital. A member of the trauma team who examines RM in the Emergency Department finds paralysis of his left arm and leg and suspects several fractured ribs.

Despite treatment with oxygen, RM is becoming hypoxic and ventilation treatment is started. A CT scan shows a subarachnoid haemorrhage. He is transferred to the Intensive Care Unit (ICU) for continuing treatment. The neurosurgeons examine the CT images and recommend that RM is transferred to their neurological centre for further assessment and consideration of possible surgery.

RM’s parents attend the ICU and are devastated to see their son in these circumstances. The ICU consultant explains that their son may need an operation to reduce the effects of the bleeding into his brain, or to prevent further bleeding.

Show Intro
Start Quiz
When would be the best time to consider the ReSPECT process for RM?
1 / 5
Now
Yes
No
2 / 5
After transfer to the neurosurgical unit, when the prognosis will be clearer
Yes
No
3 / 5
When (if) RM regains consciousness
Yes
No
4 / 5
When (if) RM regains capacity
Yes
No
5 / 5
Only if and when RM or his parents ask for it
Yes
No
A person having an intervention

SCENARIO INTRO

TM is a 76-year-old lady. Her husband died 7 years ago, having been severely disabled by a stroke for his last 2 years of life. She has decided that, although she still enjoys life, lives independently and would like to have treatment for reversible conditions, she would not want to receive life-sustaining treatments, including CPR, ventilation or renal dialysis. She has explained her decision to her daughter who is supportive. TM visits her GP to ask how she can make sure that her wishes are known.

Show Intro
Start Quiz
Which of the following would be appropriate outcomes from this visit?
1 / 5
She sees a GP who completes a DNACPR form
Yes
No
2 / 5
She sees a GP who explains to her about ReSPECT, advance care planning and ADRTs, gives her an information leaflet and asks her to come back next week
Yes
No
3 / 5
She sees a GP who has a ReSPECT conversation with her and completes a ReSPECT form
Yes
No
4 / 5
She sees an advanced nurse practitioner who says that she can’t help her and tells her to book an appointment with a doctor
Yes
No
5 / 5
She sees a GP who tells her to make an appointment to discuss this with her daughter present
Yes
No

Scenario Complete

Go back

Who is for?

Learning objectives – In this module you will learn:

  • Who the ReSPECT process is for
  • When to consider the ReSPECT process
  • Who can initiate the ReSPECT process

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Anyone can participate in the ReSPECT process…

Even if they are currently well. Particular consideration should be given to the following:

People with a long-term condition, life limiting condition or disability who may deteriorate suddenly or are at risk of a sudden event.

People who were otherwise well who have deteriorated suddenly.

People at foreseeable risk of death or sudden cardiorespiratory arrest.

People having an intervention, such as major surgery.

People who are nearing the end of their life.

[0:34] The ReSPECT process is best started and the form completed when a person is relatively well…
So that, if a crisis occurs, their preferences and agreed clinical recommendations are already known and recorded. However, some people may develop an unexpected sudden, severe illness, so if such an emergency occurs in someone with no ReSPECT form, consider discussing ReSPECT and completing one as soon as is reasonably possible.

[1:00] The ReSPECT process can be used for people of all ages.

If it is used for a child or young person, it is crucial to ensure appropriate parental or legal guardian involvement.

[1:13] Any professional involved in a person’s care can initiate the ReSPECT process with endorsement from the senior clinician.
Any health or social care professional who knows the person, their circumstances, their family and other representatives may be the most appropriate to have the conversation.

It can be a GP, a hospital doctor or a senior nurse. Sometimes it can be helpful for a second professional to be involved. After discussing and documenting the agreed plan, the professional who completed it must sign it. If they are not the senior clinician in charge of the person’s care, that senior clinician must be aware and approve of the plan, and should sign to endorse it as soon as possible.


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Who is ReSPECT for?

  • Anyone can participate in the ReSPECT process, even if they are currently well, but it may be most relevant for people who have particular healthcare needs.
  • The ReSPECT process is best started and the form completed when a person is relatively well.
  • The ReSPECT process can be used for people of all ages.
  • Any professional involved in a person’s care can initiate the ReSPECT process with endorsement from the senior clinician.
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FURTHER READING
Quiz Me Next Module FAQs
A person with an advanced terminal illness

SCENARIO INTRO

AB is a 61-year-old lady who has been recently diagnosed with an advanced recurrence of pancreatic cancer. She lives with her husband, who is visually impaired; she is his full-time carer. Her husband is known to the social services team. She has no close family but has a network of friends.

Following three cycles of palliative chemotherapy, which she found very unpleasant, a repeat CT shows that the cancer is not responding. Her oncologist discusses the option of second-line chemotherapy, but she decides that she does not want to have this.

Show Intro
Start Quiz
Which of the following further actions may help her?
1 / 6
The oncologist tells her that nothing more can be done for her
Yes
No
2 / 6
She is offered referral to a palliative care team
Yes
No
3 / 6
She is guided through the ReSPECT process by a community nurse
Yes
No
4 / 6
Her GP completes a DNACPR form and telephones her to explain this
Yes
No
5 / 6
Her GP contacts her husband’s social worker
Yes
No
6 / 6
She is guided through a detailed advance care plan
Yes
No

Scenario Complete

Go back

Having a conversation about

Learning objectives – In this module you will learn:

  • How to prepare for a conversation about the ReSPECT process.
  • How to have a conversation about the ReSPECT process.
  • What to do when faced with particular challenges.

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INTRODUCTION

Introduction

The ReSPECT process is designed to empower the person and the clinician to have a two-way conversation about priorities of care and recommendations for emergency treatment. Some aspects of the ReSPECT conversation may be difficult, such as discussing limits to care and cardiopulmonary resuscitation. The following tips aim to help to prepare for a conversation guided by the ReSPECT process.

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Before you have the conversation think about

Before you have the conversation think about

People

Who should lead the conversation?

Ideally, this should be a senior clinician looking after the patient who knows them well, such as their lead consultant or a senior trainee, GP or a senior nurse. In a more urgent situation, the senior clinician holding clinical responsibility for the person should lead the conversation. Involving other colleagues with relevant expertise or significant input into their care may be helpful e.g. critical care outreach or palliative care.

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Who are you having the conversation with?

This should be the person, and where possible, their family and other representatives.

If the person has capacity for the relevant decisions, they must be involved fully with the process of shared decision-making. Many people want to have the support of family or other representative in the discussion, and some may choose to have a family member or other representative advise them on what choices to make. If you are asked to speak to the person’s family or other representative alone, and the person has capacity, then seek their permission first. If they do not want their family or other representative to know about their condition or their choices, they should make sure that the healthcare team knows about this so that their wishes for confidentiality can be respected.

If a person lacks capacity and has appointed a legal proxy (e.g. with power of attorney for health and welfare), the clinical team must involve them in making shared decisions on behalf of the person. Where there is no legal proxy, the clinical team must consult family or friends about a person’s situation and previously expressed views or wishes, in order to make decisions that are in that person’s best interests and for their benefit. However, the responsibility for making those decisions rests with the senior responsible clinician. The family must not be burdened with thinking that they are being asked to make these decisions.

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Which other team members should be there?

This will vary with the setting, but where possible, it is useful to have another team member with you, so that they know what was said and can reiterate the information to maintain continuity and consistency, and you can reflect on the conversation together. Having a member of another discipline present demonstrates that the team is agreed on the advice and recommendations given, and provides another perspective to support the person’s understanding and involvement in decision making. This may also be an opportunity to train junior members of the team.

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Timing

When is best to have the conversation?

Ideally, it is good to have these conversations early and in a non-urgent situation, when the person is able to make decisions and express their priorities. In the community or in an outpatient setting, there may be an opportunity to complete the ReSPECT process over more than one meeting. However, there may also be situations when recommendations are needed relatively urgently; at these times the conversation should be initiated and completed at once.

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Setting

Where to have the conversation

Where possible find a quiet and private place for the conversation. Sit so you are level with the person and other people in the room. It is important that you have the time to have the conversation, and not feel rushed or pressured. Try to turn off phones, bleeps or pagers, or where this is not possible, warn that there may be interruptions.

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Information gathering

Gathering information

  • Gathering relevant information about the person in preparation for the conversation is invaluable, such as their past and current medical history and what they are able to do for themselves. In addition, it is important to seek consensus about what interventions are appropriate should the person deteriorate with members of the multidisciplinary team and other relevant clinicians.
  • In a more urgent situation, the clinician with responsibility for the patient should gather as much information as possible about the person within the time frame without compromising best care.
  • It is also useful to understand what information the person and those important to them have already been given, their understanding of the current situation, what the future holds, and how they have responded to conversations like ReSPECT in the past.
  • It can be a challenge to understand the values and priorities of cultures different to our own and how these may impact on the person’s level of comprehension. Such values must be acknowledged and the conversation adapted accordingly, as their perception of quality of life and wishes for treatment may be very different.
  • It is essential to arrange for an interpreter where this is needed – try not to use the person’s family or other representatives to interpret.
  • Ensure those with eyesight or hearing impairments have appropriate aids.
  • Consider poor functional literacy, e.g. not being able to read forms or instructions, which may be difficult to detect due to shame and stigma. Look out for clues such as “I forgot my glasses”, “I will read it later”, or “I don’t like filling out forms.”
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During the conversation

During the conversation

Explain the purpose of the conversation

Explain that the aim is to reach a shared understanding of the person’s current and future health status and to agree and make recommendations about what care should be implemented in a future emergency situation in which they are unable to make or express choices.

“We would like to talk to you about how you are, what has been happening recently, and what might happen in the future, so that we can make sure that you receive the best care and treatment.”

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Establish how much information the person wants to receive

It is important to establish how much information the person wants, and to give information in line with their wishes. Ask them if they would like to include anyone else in the conversation.

“These conversations are not easy; are you OK to continue?” and “is there someone else that you want to involve who knows about what you think or want?”

“Sometimes people think about what might happen if they were less well in the future; is that something that you would like to talk about?”

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Establish what they know already

Establish what the person, and those with them, know already about their health and current situation, and what that information means to them. Where appropriate, you may need to correct misunderstandings at this point.

“Can you tell me what you understand about your illness?”, “how do you feel things are going?” or “how do you feel things have been in comparison to a month ago, or over the last few months?”

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Establish where possible the priorities and wishes of the person

Explore whether the person, and those with then, have thought about what might happen in the future, and what they would want in an emergency situation.

“What are the things that we need to know about you?”, “have you thought about what is important to you going forwards?”, “have you thought about what you would want in the future?” or “when you think about the future, what matters most to you?”

When there is someone representing the person, use questions like: “What do you think they would want?” or “have they ever expressed any wishes beforehand?”

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Explain the current and future clinical situation and treatment(s)

Explain the current clinical situation, what situations might happen in the future, and what treatments are and are not appropriate for the person in those situations.

“You responded so well to the treatment, we need to make sure that if this situation arises again, everyone knows what to do” or “the treatment helped this time, but we are worried that at some stage you may become more unwell – is this something that you have thought about?” or “unfortunately, we do not think that giving you more treatment is going to help, so we need to think about what we can do for you, what you would want in that situation, and what treatments or care we can give.”

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Use plain language

Avoid medical jargon and use plain language to de-medicalise and de-mystify healthcare, particularly when in emergency situations. Plain language means that the listener or reader should understand from the first time they hear or read a communication.

Examples: instead of “oral” use “by mouth”, instead of “modify” use “change”, instead of “optimal” use “best way.”

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Check their understanding

Do not assume that anyone understands everything that has been said to them. Some people may lack the confidence, experience, or are too unwell to ask clinicians for explanations or to clarify statements.

‘Teach back’ is a simple technique where you ask a person, including if there is an interpreter, to explain what has been said in their own words. If they do not articulate the conversation back correctly, explain again and repeat teach back. This may need to be repeated a few times. In some cases, it may be helpful to ask another healthcare professional to have the conversation. Diagrams and other forms of media can be used to aid understanding.

“I would like to check that we have understood each other, so can you tell me, in your own words, about what we have been discussing?” or “what will you tell your family when you get home about what we have discussed?”

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Summarise the conversation

To ensure that a person and those with them understand the what has been discussed and what will be recorded on the ReSPECT form, summarise the conversation, giving them the opportunity to comment on or confirm the recommendations. Ask them if there is anything else they would like to discuss.

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Particular Challenges

Particular Challenges

People who do not want to engage in such a conversation

Some people may not want to have a conversation – in this case, you should support them in their decision until they are ready to begin discussions. If a decision is needed more urgently, you should explain this to them and explain the need to plan in order to ensure they receive the best care possible. In a less urgent situation, you should support the person until are ready to discuss their wishes.

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What if a person does not want a ReSPECT form?

If a person does not want a ReSPECT form 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.

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What if the person or their representatives disagree with a clinical decision?

In situations where the clinical team think that a particular treatment or intervention should not be initiated in an emergency because it will not work for the person (and that therefore a ReSPECT document is needed to record this) all attempts should be made to explain this to the person, their family or their representatives. This should be done sensitively and carefully by an experienced, senior clinician. A second opinion should be offered if they do not accept the clinical decision.

If disagreement persists, full details should be documented in their health record. If necessary legal advice and a ruling by the courts may be needed, but the need for this should be very infrequent if the person and those close to them have been properly involved in fully informed discussion.

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After the conversation

After the conversation

Documentation and sharing the decisions

It is important to share the information following the conversation. This should be done by documenting a summary on the ReSPECT form, a more detailed documentation in their health records or in some cases a clinic letter, and informing the wider health and care team. If you had someone with you during the conversation, they can relay the information to their teams to ensure everyone is aware of the plan.

It takes time to do the documentation – however the better the documentation, the better the shared information.

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Reflection and feedback

Everyone is different in their approach and style for these conversations. You evolve your own style with time and experience. Just like learning a practical procedure, skills for having difficult conversations need to be practiced and it is helpful to reflect and listen to feedback.

As those who work in health and social care, we can learn a lot by observing our more experienced colleagues and learning from conversations that went well and those that did not. If you are leading the conversation and had other team members in the room with you, they may be able to provide feedback. You can reflect on what aspects went well, what did not go so well, how certain points were phrased, and if those in the room understood what was being said.

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Quiz Me Next Module FAQs
A person with unexpected deterioration

SCENARIO INTRO

RM is a 22-year-old student who is involved in a road accident. He is found unconscious, brought to the nearest hospital and found to have a subarachnoid haemorrhage. He is intubated and ventilated transferred to the Intensive Care Unit (ICU).

RM’s parents arrive and the ICU consultant explains that their son may need an operation to reduce the effects of the bleeding into his brain, or to prevent further bleeding. The consultant considers the ReSPECT process.

Show Intro
Start Quiz
Who should be involved in the initial ReSPECT conversation for RM
1 / 5
The ICU consultant
Yes
No
2 / 5
An ICU nurse
Yes
No
3 / 5
RM’s parents
Yes
No
4 / 5
The local transplant coordinator
Yes
No
5 / 5
RM’s GP
Yes
No
A person with unexpected deterioration

SCENARIO INTRO

RM is a 22-year-old student who is involved in a road accident. He is found unconscious, brought to the nearest hospital and found to have a subarachnoid haemorrhage. He is intubated and ventilated transferred to the Intensive Care Unit (ICU).

RM’s parents arrive and the ICU consultant explains that their son may need an operation to reduce the effects of the bleeding into his brain, or to prevent further bleeding. The consultant considers the ReSPECT process.

Show Intro
Start Quiz
What preparation is needed before the conversation?
1 / 4
The ICU consultant reads all the information on the ReSPECT website
Yes
No
2 / 4
The parents read the information leaflet
Yes
No
3 / 4
The ICU consultant and nurse discuss RM’s condition
Yes
No
4 / 4
Section 2 of the form is completed
Yes
No
A person with a chronic health condition

SCENARIO INTRO

IA is a 65-year-old retired civil engineer from Bangladesh. He lives with his wife, who speaks little English, and two of his four children. He has advanced kidney failure and agrees to start dialysis.

A dialysis nurse specialist tells IA about ReSPECT and offers him an information leaflet, but he says that he does not want a leaflet or to discuss ReSPECT and have a form at present.

Show Intro
Start Quiz
What should any health professional do if a person says that they do not want to discuss ReSPECT or have information about it?
1 / 5
Consider whether there are cultural or religious reasons for their decision
Yes
No
2 / 5
Consider whether they have any difficulty in understanding what has been explained, or in reading information in the format offered
Yes
No
3 / 5
Tell them that if they do not want to discuss ReSPECT, a form will be completed without their involvement
Yes
No
4 / 5
Record in their health record that they have been offered ReSPECT but do not want to discuss it yet
Yes
No
5 / 5
Respect their choice, but offer them opportunities to reconsider later, if and when they want to do that
Yes
No
A person with a chronic health condition

SCENARIO INTRO

IA is a 65-year-old with a history of type 2 diabetes and advanced kidney failure receiving dialysis. A dialysis nurse specialist tells IA about ReSPECT and offers him an information leaflet, but he says that he does not want a leaflet or to discuss ReSPECT and have a form at present.

Six months later, he has a heart attack (non-ST-elevation myocardial infarction). He receives treatment in the Coronary Care Unit and an echocardiogram shows that the pumping action of his heart is severely reduced. The cardiology registrar suggests that he reconsiders having a ReSPECT form, so that the nurses and other team members would know what to do if he had a sudden further problem with his heart and could not make decisions at the time. He decides that he would now like this.

Show Intro
Start Quiz
Who may be best placed to start the ReSPECT conversation in this setting?
1 / 6
The cardiology registrar
Yes
No
2 / 6
The dialysis nurse specialist
Yes
No
3 / 6
A coronary care nurse
Yes
No
4 / 6
A consultant cardiologist
Yes
No
5 / 6
His GP
Yes
No
6 / 6
A palliative care consultant
Yes
No
A person with a chronic health condition

SCENARIO INTRO

IA is a 65-year-old retired civil engineer from Bangladesh with a history of type 2 diabetes and advanced kidney failure receiving dialysis. He lived with his wife, who speaks little English, and two of his four children.

Six months later, he has a heart attack (non-ST-elevation myocardial infarction). He receives treatment in the Coronary Care Unit and an echocardiogram shows that the pumping action of his heart is severely reduced. The cardiology registrar suggests that he reconsiders having a ReSPECT form, so that the nurses and other team members would know what to do if he had a sudden further problem with his heart and could not make decisions at the time. IA feels ready to discuss this.

Show Intro
Start Quiz
What preparation is essential for this ReSPECT conversation?
1 / 6
A formal assessment of his capacity
Yes
No
2 / 6
Finding a quiet room with comfortable seating
Yes
No
3 / 6
Ensuring minimal chance of interruption
Yes
No
4 / 6
Planning a date and time when all his family can be there
Yes
No
5 / 6
Knowing details of his condition and its treatment and prognosis
Yes
No
6 / 6
Discussion between cardiology and renal teams
Yes
No

Scenario Complete

Go back

Completing the form (The practical stuff)

Learning objectives – In this module you will learn:

  • What should be recorded on a ReSPECT form.
  • Where to store the ReSPECT form.
  • How to carry out the ReSPECT process for a person lacking capacity.

Remember, to save content to your cards press this symbol:

INTRODUCTION

Introduction

Click any box on the form to see an explanation of how it should be filled in.

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SIDE 1
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SIDE 2
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FURTHER READING

Storing the form

Once a form is completed, it is important that the person keeps it with them, and that it is readily available for professionals who may need to see and use it.

At home the ReSPECT form should be kept somewhere accessible, so that their family or other representatives know exactly where to find the ReSPECT form if an emergency occurs. In a hospital, care home, hospice or other organisation the form must be stored in a clearly defined and rapidly accessible place, whether it is in paper or electronic format.

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Capacity - Adults

If the person has capacity for the relevant decisions, they must be involved fully with the process of shared decision-making. Many people want to have the support of family or other representative in the discussion, and some may choose to have a family member or other representative advise them on what choices to make. If you are asked to speak to the person’s family or other representative alone, and the person has capacity, then seek their permission first. If they do not want their family or other representative to know about their condition or their choices, they should make sure that the healthcare team knows about this so that their wishes for confidentiality can be respected.

If a person lacks capacity and has appointed a legal proxy (e.g. with power of attorney for health and welfare), the clinical team must involve them in making shared decisions on behalf of the person. Where there is no legal proxy, the clinical team must consult family or friends about a person’s situation and previously expressed views or wishes, in order to make decisions that are in that person’s best interests and for their benefit. However, the responsibility for making those decisions rests with the senior responsible clinician. The family must not be burdened with thinking that they are being asked to make these decisions.

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Capacity - Children and young persons

If the young person has sufficient maturity and capacity for the relevant decisions, they should be involved in the process of shared decision-making. Some parents may advise that they wish to exclude their child from these discussions. It is important to explore and understand their reasoning for such a request and to seek an appropriate approach through which to include their child in the process.

For young people, under the age of 16, a pragmatic line must be steered regarding their involvement in order to establish a position that is ethically acceptable to all those involved. For those over 16 the Mental Capacity Act applies and their involvement in the decision making should be guided accordingly.

If a young person over 16 lacks capacity their parents will normally act as their legal proxy. As such the clinical team must involve them in making shared decisions on behalf of the person. Where this is not the case, a person will be identified by social services to fulfil the legal proxy role.

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Real world tips

  • The ‘S’ in ReSPECT stands for ‘summary’ – in an emergency, people may not have time to read lots of text, so be clear and succinct – the information should be accessible at a glance. You can signpost to clinical records where a more detailed documentation of conversations and preferences exists.
  • Write legibly – so there are no misinterpretations.
  • Think about who is going to read the form – use plain English, avoiding medical jargon and abbreviations as much as possible, as the form may be read or acted on by people with little or no medical or specialist knowledge. Think about who may need to use the form to help them make immediate decisions e.g. ambulance clinicians, out-of-hours doctors, community nurses, care home staff, hospital nurses and doctors.
  • Think about where the form may be used – and where the person may be when an emergency occurs, and ensure that the recommendations are relevant to all those settings.
  • Take time to complete the form – time spent discussing preferences and completing the form well will help ensure that the person gets their agreed treatment, and will save time during their further care, especially in a crisis, when decisions have to be made without delay.
  • Sign the correct boxes – take care to sign the correct boxes on the form to indicate the priorities of care and the recommendation about CPR. Signing the incorrect boxes can have serious consequences.
  • Sign the form – the person who has had the conversation and completed the form with the person should be the first signatory. Add a legible signature and legible name and registration number. The senior responsible clinician, such as the person’s GP, consultant, or senior nurse, is responsible for the plan and if they are not the initial signatory they should sign to endorse it as soon as possible.
  • Inform others looking after the person – if a form has been completed or updated ensure those involved in the person’s care are up to date with the recommendations.
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SAMPLE FORMS
Preview Scenario 1 AB's Form Preview Scenario 2 IA's Form Preview Scenario 3 RM's Form Preview Scenario 4 NF's Form Preview Scenario 5 TM's Form
Quiz Me Next Module FAQs
A person lacking mental capacity

SCENARIO INTRO

NF is an 84-year-old retired nurse. She has severe visual impairment, uses a hearing aid, and has vascular dementia. She has been living in a care home for 2 years. Her daughter lives nearby and sees her at least weekly. Her son lives further away and visits every few weeks.

A community matron knows NF and her family well, and after confirming NF’s lack of capacity for decisions related to her health and future care, and recording that assessment in the health record, she has a ReSPECT conversation with the son and daughter. They tell her that their mother had given them Lasting Power of Attorney to make decisions for her.

Show Intro
Start Quiz
What further information does the community matron need?
1 / 5
What type of LPA do they hold?
Yes
No
2 / 5
Do they hold it jointly or individually?
Yes
No
3 / 5
Has it been registered with the Office of the Public Guardian (OPG)?
Yes
No
4 / 5
Does it include the power to decide about life-sustaining treatments?
Yes
No
5 / 5
Has NF made an Advance Decision to Refuse Treatment (ADRT)?
Yes
No
A person with unexpected deterioration

SCENARIO INTRO

RM is a 22-year-old student who is involved in a road accident. He is found unconscious, brought to the nearest hospital and found to have a subarachnoid haemorrhage. He is intubated and ventilated transferred to the Intensive Care Unit (ICU).

RM’s parents arrive and the ICU consultant explains that their son may need an operation to reduce the effects of the bleeding into his brain, or to prevent further bleeding. The ReSPECT process is discussed and they reach a shared decision that, there is still some possibility that he could make a good recovery, and the focus of care in an emergency should be on treatments that may help to sustain his life, including cardiopulmonary resuscitation. A ReSPECT form is completed, summarising these recommendations.

Show Intro
Start Quiz
Which of the following should form part of the ReSPECT process and ReSPECT form for RM?
1 / 5
Decisions about the content of his form should be made in his best interests
Yes
No
2 / 5
His parents should be asked to decide whether he should receive CPR
Yes
No
3 / 5
A detailed assessment of RM’s capacity should be documented in his health records
Yes
No
4 / 5
His parents should be told that, as he is an adult, they have no say in his treatment
Yes
No
5 / 5
His parents are told that the form is legally binding
Yes
No
A person with an advanced terminal illness

SCENARIO INTRO

AB is a 61-year-old lady with an advanced recurrence of pancreatic cancer. She lives with her husband, who is visually impaired; she is his full-time carer. Her oncologist discusses the option of second-line chemotherapy, but she decides that she does not want to have this. He offers referral to the palliative care team, which she accepts, and he tells her about ReSPECT. She says that she would like to discuss it with her husband and her GP and takes home an information leaflet.

She visits her GP, accompanied by her husband, and is supported through the ReSPECT process and completion of her ReSPECT form. The GP suggests that she discusses a more detailed advance care plan with the palliative care team.

Show Intro
Start Quiz
Which of these entries are appropriate in section 2 of her ReSPECT form?
1 / 6
Main carer for blind husband
Yes
No
2 / 6
Refused further treatment
Yes
No
3 / 6
Ca pancreas with hepatic and LN mets
Yes
No
4 / 6
Past history of carpal tunnel syndrome and left hip replacement
Yes
No
5 / 6
Cancer of pancreas, with spread to liver
Yes
No
6 / 6
Initial chemotherapy ineffective; does not want more
Yes
No
A person with a chronic health condition

SCENARIO INTRO

IA is a 65-year-old retired civil engineer from Bangladesh. He lives with his wife, who speaks little English, and two of his four children. He has a history of type 2 diabetes and reduced kidney function. Over the last twelve months his kidney function has deteriorated and he now has advanced kidney failure. He has had a previous heart attack, an episode of cellulitis in his right leg, and he is obese.

He is seen by his kidney specialist, accompanied by his wife. Dialysis is recommended, because of his advanced kidney failure, and he decides to have this treatment. The possibility of him being put on the list for a kidney transplant is also mentioned, but no firm decision is made about this.

Show Intro
Start Quiz
How could the ReSPECT process help IA at this time?
1 / 4
By ensuring that he understands his present condition and likely future progress
Yes
No
2 / 4
By recording his history of cellulitis in case of recurrence
Yes
No
3 / 4
By recording his preferences in case of a sudden complication during dialysis
Yes
No
4 / 4
By recording his wife’s communication needs in case of a future emergency
Yes
No
A person with a chronic health condition

SCENARIO INTRO

IA is a 65-year-old retired civil engineer from Bangladesh with a history of type 2 diabetes and advanced kidney failure receiving dialysis. He lives with his wife, who speaks little English, and two of his four children.

He has a heart attack (non-ST-elevation myocardial infarction) and receives treatment in the Coronary Care Unit. An echocardiogram shows that the pumping action of his heart is severely reduced, limiting his chance of having a successful kidney transplant. The clinical team explain that he can continue with dialysis and tablets to reduce the chance of rapid worsening of his heart condition.

IA understands this, but nevertheless is content with his recent quality of life, and is clear that he wants his future care and treatment to focus primarily on sustaining life, including CPR if needed. This is agreed and recorded on his ReSPECT form.

Show Intro
Start Quiz
Which of the following are appropriate entries on his ReSPECT form?
1 / 4
Wife has limited English – speaks Bengali
Yes
No
2 / 4
Came from Bangladesh 10 years ago, to work as a civil engineer
Yes
No
3 / 4
NSTEMI – echo shows EF 16%
Yes
No
4 / 4
Has haemodialysis twice a week
Yes
No

Scenario Complete

Go back

How to care for someone with a form

Learning objectives – In this module you will learn:

  • How to use the ReSPECT form in an emergency.
  • When to review the ReSPECT form.
  • How to update the ReSPECT form and what to do if we need to use a new one.

Remember, to save content to your cards press this symbol:

INTRODUCTION

Introduction

Once the ReSPECT process has been adopted in a community it can be used in the all settings – the person’s home wherever that may be, in all health and care settings, and by transport services. It is therefore important that the person keeps their ReSPECT form with them, and that it is readily available for professionals to see and use it.

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What to do if you are caring for someone with a ReSPECT form

There are two types of situation when the ReSPECT process is key: during an emergency situation when a person with a ReSPECT form is unable to make or express choices, and in a non-emergency situation, when the ReSPECT form is reviewed and may need updating.

What to do in an emergency when a person with a ReSPECT form is unable to make or express choices:

  1. Confirm

Confirm the identity of the person with the ReSPECT form and that it is the latest version of the form completed for that person.

  1. Read

Read the form to understand which recommendations may relate to your role in their care.

  1. Act

If the recommendations apply to the current emergency, and the person cannot decide for themselves, then act on the recommendations relevant to your role when caring for that person.

What to do in a non-emergency situation as a clinician:

In non-emergency situations, the recommendations may need to be reviewed and, if necessary updated or cancelled. These situations include:

  • when the person, or their representative, asks for this.
  • when there has been a significant change in the person’s condition.
  • when the person is moving, or has moved from one setting to another, such as from home to hospital.

Confirm and Read

As with all ReSPECT forms, confirm the identity of the person and that it is the latest version of the form and read it to identify how the recommendations may relate to your role in their care.

Discuss

Review and discuss the goals of care and recommendations in the light of the current situation with the person and/or their family or other representatives. If the person’s current ReSPECT form requires an amendment or update, cross through the recommendations that are no longer relevant, record the updated recommendations on the same section of the form, and confirm the review by signing section 9. Refer to local policy for specific guidelines.

The form should be cancelled and a new form completed if the goals of care and recommendations have changed significantly, or if there is no space to record an update on the current form.

ReSPECT forms that are no longer valid should be clearly marked “CANCELLED”, with two diagonal lines, your legible signature (and legible name and registration number), and the date.

Once the recommendations are updated, this information should be shared with relevant health and social care staff involved in the person’s care.


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What to do...

In an emergency when a person with a ReSPECT form is unable to make or express choices:

  • Confirm the identity of the person.
  • Read the form.
  • Act on the recommendations relevant to your role.

In a Non-emergency situation (as a clinician):

Confirm and read the form – Review and discuss the goals of care and recommendations – if amending or updating the ReSPECT form, cross through the recommendations that are no longer relevant, record the updated recommendations on the same section of the form, and confirm the review by signing section 9.

Creating a new form – Cancel a form and complete a new form if the goals of care and recommendations have changed significantly, or if there is no space to record an update on the current form.

ReSPECT forms that are no longer valid should be clearly marked “CANCELLED”, with two diagonal lines, your legible signature (and legible name and registration number), and the date.

Once the recommendations are updated share the information with relevant health and social care staff involved in the person’s care.

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Storing the form

At home the ReSPECT form should be kept somewhere accessible, so that their family or other representatives know exactly where to find the ReSPECT form if an emergency occurs. In a hospital, care home, hospice or other organisation the form must be stored in a clearly defined and rapidly accessible place, whether it is in paper or electronic format.

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FURTHER READING

How to care for someone with the ReSPECT form in the hospital

In the case of an emergency for which there are recommendations on the form, and the person cannot decide for themselves, follow the recommendations. If a situation arises that is not addressed on the form, or staff are unsure what to do, they should ask for help from their seniors, or members of the clinical team such as the doctors or nurses.

The form should be reviewed prior to transfer between wards and between hospitals. The clinical team should ensure appropriate handover, ensuring the receiving team are aware of the ReSPECT form and the person’s recommendations. Upon discharge, the clinical team should check the recommendations remain valid and consistent with the person’s preferences and clinical condition at the time of discharge. These details need to be passed on to the GP and or the community teams caring for the person. The form should be shown to the ambulance clinicians, or who may be providing the transport, and it should travel with the person.

If the person’s situation has changed such that acting on the recommendations would no longer be in their best interests, then care for the person by acting in their best interests, ideally guided by consensus decisions by a multidisciplinary team, and review the recommendations on the ReSPECT form.

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How to care for someone with the ReSPECT form in the community

In the case of an emergency for which there are recommendations on the form, and the person cannot decide for themselves, follow the recommendations. If a situation arises that is not addressed on the form, or staff are unsure what to do, they should ask for help from their seniors, or members of the clinical team such as the GP or community nurses.

Ideally, the form should be reviewed upon each encounter with the person. The community teams should ensure appropriate handover so that the wider team are aware of the ReSPECT form and the person’s recommendations. If the person is moving to a hospital, care home, hospice or other organisation then the community team should check the recommendations remain valid and consistent with the person’s preferences and clinical condition at the time of transfer. The form should be shown to the ambulance clinicians, or who may be providing the transport, and it should travel with the person.

If the person’s situation has changed such that acting on the recommendations would no longer be in their best interests, then care for the person by acting in their best interests, ideally guided by consensus decisions by a multidisciplinary team, and review the recommendations on the ReSPECT form.

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How to care for someone with the ReSPECT form in a care home

All staff should be aware of the content of the ReSPECT form, where to find it, and how to get support if the person suffers an emergency for which there are recommendations on the form and the person cannot decide for themselves. If a situation arises that is not addressed on the form, or staff are unsure what to do, they should escalate the situation to the senior nurse, care home manager or the GP.

If a person is to be transferred to hospital, the form should be shown to the ambulance clinicians and should travel with the person.

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How to care for someone with the ReSPECT form in a hospice

All staff should be aware of the content of the ReSPECT form, where to find it, and how to get support if the person suffers an emergency for which there are recommendations on the form and the person cannot decide for themselves. If a situation arises that is not addressed on the form, or staff are unsure what to do, they should get help from the senior nurse, hospice manager or doctors.

If a person is to be transferred to hospital or home the form should be shown to the ambulance clinicians and should travel with the person.

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How to care for a child or young person with a ReSPECT form

Advance care planning is already well established in children’s services. Frameworks like the Child and Young Persons Advance Care Plan (CYPACP) are widely used, and where time allows, should be the primary planning process used for any child with complex or life limiting conditions. The ReSPECT process fully integrates with such plans by providing a universally recognised, concise summary, of the family’s preferences regarding treatments that might be required in an emergency. Where an advance care plan has been completed it will usually be possible to complete a ReSPECT form using the emergency preferences that have already been recorded in the plan.

 

The principles surrounding the ReSPECT process and completion of the form are essentially the same for babies, children and young people. The key difference is that, on most, but not all occasions, the child’s parents (or those holding parental responsibility) will be the principle decision makers. This process should only be facilitated in this context by health professionals who are fully conversant with the ethical and legal frameworks pertinent to consent in childhood.

 

Wherever possible the wishes of the child should be established and given due weight to influencing the recommendations that are recorded (irrespective of age). Where the patient is a young person (older child), and demonstrates competence with regard to understanding the issues at hand, their wishes must be given significant weighting. Should their wishes be in conflict with those expressed by their parents, and this cannot be resolved, it may be necessary to seek legal advice before completing any documentation.

 

It is important to note that the Mental Capacity Act applies to patients over the age of 16 and therefore its principles must be applied in this age group

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Quiz Me FAQs
A person lacking mental capacity

SCENARIO INTRO

NF is an 84-year-old retired nurse. She has severe visual impairment, uses a hearing aid, and has vascular dementia. She has been living in a care home for 2 years. Her daughter and son have Lasting Power of Attorney to make decisions for her health and welfare.

A community matron knows NF and her family well, and after confirming NF’s lack of capacity for decisions related to her health and future care, and recording that assessment in the health record, she has a ReSPECT conversation with the son and daughter. She completes a ReSPECT form with her agreed priority of care being to focus on comfort, and with agreed recommendations that she should be considered for admission to hospital for treatment of a reversible problem such as infection, but would not want to receive cardiopulmonary resuscitation or be admitted to an intensive care unit for treatments such as ventilation or renal replacement therapy.

6 weeks later, a carer finds NF lying on the floor moaning incoherently. The nurse in charge at the care home is called to help. When they attempt to move NF she screams and appears to be in pain. An out-of-hours GP attends and suspects that she has a fractured neck of femur.

Show Intro
Start Quiz
What should the GP do?
1 / 5
Prescribe analgesia by injection?
Yes
No
2 / 5
Contact the son and daughter?
Yes
No
3 / 5
Read her ReSPECT form?
Yes
No
4 / 5
Infer from the recommendations that she should not be sent to hospital?
Yes
No
5 / 5
Dial 999 and send her to the nearest Emergency Department?
Yes
No
A person lacking mental capacity

SCENARIO INTRO

NF is an 84-year-old retired nurse. She has severe visual impairment, uses a hearing aid, and has vascular dementia. She has been living in a care home for 2 years. Her daughter and son have Lasting Power of Attorney to make decisions for her health and welfare.

NF has a ReSPECT form with the agreed priority of care being to focus on comfort, and agreed recommendations that she should be considered for admission to hospital for treatment of a reversible problem such as infection, but would not want to receive cardiopulmonary resuscitation or be admitted to an intensive care unit for treatments such as ventilation or renal replacement therapy.

A carer finds NF lying on the floor moaning incoherently and appears to be in pain. An out-of-hours GP attends and suspects that she has a fractured neck of femur. After speaking to her daughter (her son was not contactable) the GP arranges hospital admission with the orthopaedic team for treatment of her hip fracture.

Show Intro
Start Quiz
When the ambulance arrives, which of the following is correct?
1 / 4
As the patient has a ReSPECT form, no other handover is needed.
Yes
No
2 / 4
The GP should be there to give handover personally.
Yes
No
3 / 4
The ReSPECT form should be kept at the care home in case it gets lost at the hospital.
Yes
No
4 / 4
The ambulance clinicians do not need to know what is on the ReSPECT form.
Yes
No
A person lacking mental capacity

SCENARIO INTRO

NF is an 84-year-old retired nurse. She has severe visual impairment, uses a hearing aid, and has vascular dementia. She has been living in a care home for 2 years. Her daughter and son have Lasting Power of Attorney to make decisions for her health and welfare.

NF has a ReSPECT form with the agreed priority of care being to focus on comfort, and agreed recommendations that she should be considered for admission to hospital for treatment of a reversible problem such as infection, but would not want to receive cardiopulmonary resuscitation or be admitted to an intensive care unit for treatments such as ventilation or renal replacement therapy.

A carer finds NF lying on the floor moaning incoherently and appears to be in pain with a suspected fractured neck of femur. After speaking to her daughter (her son was not contactable) the GP arranges hospital admission with the orthopaedic team for treatment of her hip fracture.

NF is seen in the ED by the orthopaedic registrar, sent for x-ray and transferred to the ward. On his ward round, the consultant confirms the diagnosis of fractured neck of femur and feels that hip replacement would be the most effective way of relieving pain and restoring mobility.

Show Intro
Start Quiz
What should the consultant do?
1 / 4
Seek informed consent for surgery from the son and/or daughter.
Yes
No
2 / 4
Cancel her ReSPECT form in case she needs ICU care after surgery.
Yes
No
3 / 4
Refuse to operate unless her DNACPR recommendation is cancelled.
Yes
No
4 / 4
Discuss her treatment plan with the multidisciplinary team.
Yes
No
A person with unexpected deterioration

SCENARIO INTRO

RM is a 22-year-old student who is involved in a road accident. He is found unconscious, brought to the nearest hospital and found to have a subarachnoid haemorrhage. He is intubated and ventilated transferred to the Intensive Care Unit (ICU).

The ICU consultant explains to RM’s parents that their son may need an operation to reduce the effects of the bleeding into his brain, or to prevent further bleeding. The ReSPECT process is discussed and they reach a shared decision that, there is still some possibility that he could make a good recovery, and the focus of care in an emergency should be on treatments that may help to sustain his life, including cardiopulmonary resuscitation. A ReSPECT form is completed, summarising these recommendations.

RM is transferred to the neurological centre and a CT angiography shows an aneurysm as the cause of the bleeding requiring an operation to clip the aneurysm to reduce the risk of further bleeding. The neurosurgeon explains this to RM’s parents and they discuss the ReSPECT form and agree that the entries are still correct.

The aneurysm clipped is as planned. After a few days, the sedation is reduced and RM is weaned from the ventilator, is able to breathe for himself, and he starts to speak. He is well enough to be transferred to the neurosurgical ward.

Show Intro
Start Quiz
What should the neurosurgical team do about the ReSPECT form?
1 / 4
Cancel it as he is no longer at high risk of death or cardiac arrest
Yes
No
2 / 4
Ask his parents if they still want him to have it?
Yes
No
3 / 4
Explain it to RM and give him the chance to have a new form based on his personal preferences.
Yes
No
4 / 4
Leave it in place unchanged, as he is getting better and should still be for full and active treatment
Yes
No
A person with an advanced terminal illness

SCENARIO INTRO

AB is a 61-year-old lady with an advanced recurrence of pancreatic cancer. She has decided that she does not want second-line chemotherapy. She has read about the ReSPECT process and has come to see her GP. Following the ReSPECT conversation, AB and her GP agree that her priority for care and the recommendations are summarised in section 4 of her ReSPECT form. She is given the form to take home.

Show Intro
Start Quiz
What should she do with her ReSPECT form?
1 / 5
File it away with her will in a binder on the bookshelf
Yes
No
2 / 5
Keep it handy
Yes
No
3 / 5
Tell her husband where to find it
Yes
No
4 / 5
Give it to her solicitor
Yes
No
5 / 5
Put it in her handbag when she goes shopping
Yes
No

Scenario Complete

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Teaching modules

The teaching modules will explain the ReSPECT process, who it’s for, how to fill in a ReSPECT form, how to prepare for a conversation and how to care for someone with a form.

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Module Content

Each module contains essential information and further reading if you would like to find out more. Essential information can be read, watched and listened to depending on your preference.

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Learning Tools

Example scenarios with questions will enable you to apply your learning to hypothetical situations. There are also tools designed to help you prepare and de-brief before and after real life ReSPECT conversations.

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About This App
What is a Module?

The teaching modules will explain the ReSPECT process, who it’s for, how to fill in a ReSPECT form, how to prepare for a conversation and how to care for someone with a form.

Each module contains essential information and further reading if you would like to find out more. Essential information can be read, watched and listened to depending on your preference.

What are the Practical Tools?

There are tools designed to help you prepare and de-brief before and after real life ReSPECT conversations, as well as example scenarios with questions which enable you to apply your learning to hypothetical situations

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Profiles

Which of these people do you think should be offered the ReSPECT process at present? Choose ‘yes’ or ‘no’.  An explanation will be given for the answer to each.
1 / 19

A person on a ventilator in an intensive care unit (ICU)

  • A person on a ventilator in an ICU is already receiving life-sustaining respiratory support. Whilst there are many possible reasons for needing such treatment, anyone receiving such intensive care is likely to be at risk of complications, and may have specific treatment needs in the event of a sudden change in their condition.

  • The ReSPECT process has the potential to help anyone receiving life support or other intensive treatment by recording a summary plan for their care and treatment in the event of a sudden complication or further deterioration in their condition, ensuring that immediate treatment decisions in such a crisis are person-centred. Being on a ventilator doesn’t necessarily mean that a person cannot communicate and does not have the capacity to participate in the ReSPECT process. Each person must be assessed as an individual, and involved in planning their care if that is possible. If they lack capacity to be involved, their family or other representatives must be involved in the ReSPECT process to determine and record recommendations about realistic care and treatment that are in the person’s best interests.

Yes
No
Next Profile
2 / 19

A person who has had a DNACPR form in place for 3 years

  • If a person has had a DNACPR form in place for 3 years, some anticipatory planning has already taken place, but the degree of involvement of the person in that planning may not be certain. As ReSPECT allows advance recommendations about CPR to be considered in the context of a broader plan for care and treatment in a future emergency, it would be appropriate to offer the ReSPECT process to this person and review the recommendation about CPR with them as part of the process. It will be important to follow the ReSPECT process systematically, and to avoid starting by discussing the DNACPR recommendation.

  • The ReSPECT process offers this person an opportunity to have a more complete plan for their care and treatment in a future emergency than a DNACPR form, and to remove or avoid some of the negative connotations that a DNACPR recommendation may carry. Completion of the ReSPECT process and form will make the previous DNACPR form redundant.

Yes
No
Next Profile
3 / 19

A person admitted to hospital following acute myocardial infarction (AMI)

  • A person admitted to hospital following AMI is likely to be considered for invasive investigation and treatment, and is at increased risk of serious complications of their condition or its treatment, including sudden cardiac arrest, stroke and severe bleeding. In that setting, making a plan for their care and treatment in the event of any such emergency is part of good-quality care. Many people in that setting will want to be considered for all potentially life-sustaining treatments should they become relevant, but some may choose not to receive specific treatments. For example, for various reasons, some may not want CPR or some may not want blood transfusion.

  • The ReSPECT process can help a person admitted to hospital following AMI by making sure that they understand their condition and its treatment, recording their priorities of care, and recording clear, agreed recommendations for their care and treatment in the event of a sudden complication of their AMI or its treatment. It can help to ensure that a person’s emergency treatment is based on their wishes, beliefs and preferences, and not on assumptions by clinicians faced with an emergency for which there has been no advance planning.

Yes
No
Next Profile
4 / 19

A person just diagnosed with depression

Depression is a disturbance of the mind causing a persistently low mood. It can vary in severity and duration and, in some people, may lead to negative thoughts that they would not have at other times, e.g. after recovery from a depressive illness.

  • At its most severe, depression can be life-threatening because it can make a person feel suicidal or lacking the will to live. Some people with depression may lack mental capacity for certain decisions.

  • Depression is not a condition that should prompt consideration of the ReSPECT process. Great care would be needed to assess whether a person with depression has the capacity to understand and make the same shared decisions about their care and treatment in a future emergency that they would make after treatment of and recovery from an episode of depression. If a person has just been diagnosed with depression, this is unlikely to be a good time to discuss the ReSPECT process with them, unless they have some other health condition to warrant urgent advance care planning of this nature.

Yes
No
Next Profile
5 / 19

A person with acute pneumonia

Pneumonia is a serious, acute lung infection.

  • People who are elderly, who have chronic illnesses, or who are immunocompromised are at a higher risk of suffering pneumonia or coming to harm from it.

  • The ReSPECT process can help someone with  acute pneumonia. If they are elderly, have a chronic condition or are immunocompromised, it would have been better to have offered them the opportunity to go through the ReSPECT process and make a plan before they developed the acute infection. However, now that they have an acute illness there is still an opportunity to make shared decisions and to plan for their care and treatment in the event of a sudden serious complication in which they are unable to make decisions. After making sure that they understand their condition, its treatment and likely outcomes, the process records their priorities for their care and clear recommendations for their treatment in an emergency. As they have an acute illness that could improve or deteriorate rapidly, it is important to consider frequently whether those recommendations are still appropriate, and to review the content of their ReSPECT form if there is any substantial change in their condition, whether that is improvement or deterioration.

Yes
No
Next Profile
6 / 19

A person with a long QT syndrome

Long QT syndromes are a group of relatively rare, usually inherited heart conditions that cause problems with the electrical activity of the heart.

  • Many people with a long QT syndrome are at increased risk of sudden cardiac arrest. For many, that risk can be reduced with regular oral treatment. However, in a person with a long QT syndrome some commonly used anti-arrhythmic drugs must be avoided, as they will increase the risk of further dangerous heart rhythms.

  • The ReSPECT process can help someone with long QT syndrome by making sure that they understand their condition and its treatment, recording their diagnosis, their treatment goals, and clear, agreed recommendations for their care and treatment in a future emergency, including the actions that should follow an episode of ventricular arrhythmia, and treatments that must be avoided (e.g. amiodarone).

Yes
No
Next Profile
7 / 19

A person referred for major elective surgery

All major operations carry a risk of serious complications, including death.

  • After some operations there will be planned admission to an intensive care unit for monitoring and ongoing treatment.

  • The ReSPECT process can help someone referred for major elective surgery by making sure that they understand their condition and its treatment and involving them in advance planning for their realistic care and treatment in the event of a complication. The precise recommendations that will be discussed and agreed with any individual will vary according to the nature and purpose of their surgery, the nature and prognosis of any underlying health problems, their perception of their quality of life and – of course – their own personal priorities for their care. Therefore, recording prior to the operation agreed recommendations for care and treatment in a future emergency is invaluable.

Yes
No
Next Profile
8 / 19

A person with a learning disability

A learning disability is a reduced intellectual ability and difficulty with everyday activities (e.g. household tasks, socialising or managing money), which affects someone for their whole life. Individuals may be affected differently, with some having mild disability to others having severe or profound disability.

  • Some people’s limited ability to understand complicated information may affect their mental capacity to make decisions. When a person with a learning disability suffers an acute illness or injury, they may not be able to make informed decisions about their emergency treatment or communicate the things that are important to them.

  • The ReSPECT process can help someone with a learning disability by recording the nature and degree of their disability, their priorities of care, and clear, agreed recommendations for their realistic care and treatment in a future emergency. Where the person with a learning disability lacks the capacity to participate in the ReSPECT process, the plan should be made in their best interests in consultation with those who know them well.

Yes
No
Next Profile
9 / 19

A person with disabling rheumatoid arthritis

Rheumatoid arthritis is a chronic progressive disease in which inflammation in the joints causes pain, deformity and disability.

  • The severity of symptoms and disability varies greatly among individuals, at different stages of the disease, and in response to treatment. Some people with rheumatoid disease are susceptible to acute episodes of joint inflammation, and in some their treatment may make them susceptible to acute, potentially life-threatening infection.

  • The ReSPECT process can help someone with rheumatoid arthritis by making sure that they understand their condition and its treatment, recording their diagnosis, important disabilities and key information about their treatment, their priorities of care, and clear, agreed recommendations for their realistic care and treatment in a future emergency. People must be given the opportunity to identify what is important to them and what realistic treatments they would or would not wish to be considered for in a future emergency. Their choices will be influenced by their quality of life and prospects for future improvement or deterioration. Their priorities and the agreed recommendations may change as their condition progresses, so it will be important to review these with them as this happens.

Yes
No
Next Profile
10 / 19

The partner of a person with a terminal illness

  • When someone close to them is terminally ill or has a serious illness, people often think about the types of care and treatment that they would or would not want to be considered for if they became seriously ill themselves. Caring for those close to a terminally ill person is an integral part of good end-of-life care. Whilst discussing ReSPECT routinely with all those close to a dying person would be insensitive, if someone asked questions about or expressed an interest in making an advance plan for their own care, they should be offered information about ReSPECT and other types of advance planning

  • The ReSPECT process can help such people by enabling them to understand their own current state of health, to record their priorities for their care, and to record clear recommendations for their care and treatment in a future emergency. Remember that ReSPECT is a summary to guide decision-making only in a future emergency, so if people want to make a broader advance care plan, or a legally binding refusal of specific treatment (ADRT) they should be supported in doing that as well.

Yes
No
Next Profile
11 / 19

A person with metastatic cancer

Metastatic cancer includes a wide range of cancer types with varying degrees of prognosis.

  • Generally, people with metastatic cancer have a poor prognosis; however, people with some types of metastatic cancer can live for many years.

  • The ReSPECT process can help someone with advanced or metastatic cancer by making sure that they understand their condition and its treatment, recording their diagnosis, their priorities of care, and clear, agreed recommendations for their realistic care and treatment in a future emergency. If a ReSPECT form is completed with someone whose metastatic cancer is not causing them troublesome symptoms or disability, or is not yet at an advanced stage, their priorities and the agreed recommendations may change as their condition progresses, so it will be important to review these with them as this happens.

Yes
No
Next Profile
12 / 19

A person who has made an Advance Decision refusing any life-sustaining treatment

An Advance Decision to Refuse Treatment (ADRT) is a legally binding document (in England & Wales) in which an adult refuses one or more specific treatments.

  • To be valid, an ADRT refusing life-sustaining treatment must state that it is refused even if the person’s life is at risk. ADRTs can be recorded in varying formats, with which health and care professionals may not be familiar.

  • The ReSPECT process and form work well alongside other planning documents such as an ADRT. The ReSPECT form has a standard format intended to make it easy to find relevant detail quickly in an emergency. If a person has made an ADRT, the ReSPECT form should draw attention to this in section 2. The ReSPECT form allows this to be considered in the context of the person’s broad goals of treatment, together with other agreed recommendations about their realistic care and treatment in a future emergency. If the ADRT is refusing life-sustaining treatment, the ReSPECT form must recommend that CPR is not attempted.

Yes
No
Next Profile
13 / 19

A person with a history of anaphylaxis

Anaphylaxis is a serious, life-threatening allergic reaction (e.g. to nuts, eggs, bee stings or a drug). Some episodes are rapid in onset and cause collapse, hypotension and confusion or impaired consciousness. Treatment of an anaphylactic reaction includes immediate injection of adrenaline.

  • Many susceptible individuals carry a pre-filled syringe containing adrenaline for emergency use. Treated promptly and correctly, many people with anaphylaxis will make a full recovery.

  • The ReSPECT process can help someone susceptible to anaphylaxis by making sure that they understand their condition and its treatment, recording their risk of anaphylaxis (and the trigger if known), and a clear recommendation regarding treatment of an episode (i.e. adrenaline and fluids). For most susceptible people, emergency care and treatment will focus on life-sustaining treatment, unless they have specific wishes or some other condition leading to a different recommendation.

Yes
No
Next Profile
14 / 19

A person with advanced heart failure

Heart failure is a chronic condition in which the heart’s pumping efficiency is reduced.

  • People with heart failure vary greatly in the severity of their symptoms and in the resulting disability. Whilst treatment can be very effective in controlling symptoms and prolonging life, for many there will come a time when their symptoms are not well controlled, when they become increasingly disabled by fatigue and breathlessness, and when their goal of treatment will focus on maintaining comfort rather than prolonging life. Furthermore, most people with heart failure have an increased risk of a sudden deterioration, including a risk of sudden cardiac arrest.

  • The ReSPECT process can help someone with heart failure by making sure that they understand their condition and its treatment, recording their diagnosis, their priorities of care, and agreed recommendations for their realistic care and treatment. For those who engage with the ReSPECT process at an early stage, it will be important to review their plan as their condition progresses, enabling them to reconsider their priorities for their care, and the recommendations for treatment to remain relevant and realistic. For those with an implantable cardioverter defibrillator and advanced heart failure, discussions should include consideration of deactivation of their device as they are coming towards the end of their lives, to protect them from the distress of multiple shocks as they are dying.

Yes
No
Next Profile
15 / 19

A person with no specific health problems

  • People can experience a sudden unforeseen health crisis at any time in their lives, due to either a sudden illness or a severe injury.

  • Some people prefer to plan for the unexpected, whereas others prefer to take a reactive approach. The ReSPECT process can help someone who wants to plan ahead to have a clear record of their priorities of care and agreed recommendations for their care and treatment in a future emergency in which they are unable to make decisions.

Yes
No
Next Profile
16 / 19

A person with dementia

Dementia is a disorder of the brain that causes decline in cognitive function, such as impairment of memory, thinking, problem-solving or communication.

  • People with dementia may lose the ability to make decisions. In advanced dementia, people may need help with their activities of daily living.

  • The ReSPECT process can help someone with dementia by making sure that they (or those close to them if they lack capacity) understand their condition and its treatment, recording their diagnosis and their priorities of care, together with clear, agreed recommendations for their realistic care and treatment in an emergency. Ideally, the ReSPECT process should be introduced early so that they can contribute to conversations and decisions about their treatment recommendations. Those with more advanced dementia may lack the mental capacity to contribute to any discussions, in which case their family or other representatives must be involved in planning for their care and treatment in a future emergency.

Yes
No
Next Profile
17 / 19

A person who doesn’t want to be involved in planning their treatment

  • The ReSPECT process involves shared decision-making, unless this is impossible. If a person doesn’t want to be involved in advance planning, or doesn’t want a ReSPECT form, their wishes should be respected, and attempts should not be made to coerce them into discussing ReSPECT.

  • Whilst a person may not want to be involved in advance planning of their future care and treatment, some people will want this to be done for them by their healthcare team, or by their healthcare team in consultation with their family or others close to them. If a person declines information about and discussion of ReSPECT, explore whether they would like their family and other representatives to be involved in planning their treatment, and whether they want their healthcare team to make a plan for their treatment in a future emergency. Remember always to make clear that a person may change their mind and discuss ReSPECT at any time, even if they were not ready or willing to do so initially

Yes
No
Next Profile
18 / 19

A person with epilepsy

Epilepsy is a chronic disorder of the brain that causes sudden and recurrent seizures.

  • Some people experience seizures only rarely; others have frequent seizures that may be difficult to prevent or to treat. The type and dose of anticonvulsant treatment taken to prevent seizures can vary from one person to another, as can the treatment that is most effective in treating a prolonged seizure.

  • The ReSPECT process can help someone with epilepsy by making sure that they understand their condition and its treatment, recording their diagnosis, a focus on life-sustaining treatments and clear recommendations for their individual treatment needs should they experience a prolonged seizure.

Yes
No
Next Profile
19 / 19

A person with Addison’s disease

In Addison’s disease (primary adrenal insufficiency) the adrenal glands do not produce enough steroid hormones.

  • A person with Addison’s disease must take regular steroid replacement tablets and an illness such as an infection can cause rapid deterioration leading to collapse, vomiting, severe hypotension and confusion. In this life-threatening emergency, they must be given steroid injections and intravenous fluids without delay. Addison’s disease is treatable and people with it are generally expected to recover following prompt treatment of such an acute episode (‘Addisonian crisis’).

  • The ReSPECT process can help someone with Addison’s disease, by making sure that they understand their condition and its treatment, recording their diagnosis, a focus on life-sustaining treatments and clear recommendations for their treatment in an acute episode.

Yes
No
Next Profile

Complete

Go to Modules

Scenarios

Work through the following case scenarios to learn about the ReSPECT process. Choose ‘yes’ or ‘no’ to answer each question. An explanation will be given for the answer to each. You can track your progress. If you cannot complete the scenarios in one sitting you have the option to come back to where you left off.
A person having an intervention

Question 1

SCENARIO INTRO

TM is 76 years old. Her husband died 7 years ago, having been severely disabled by a stroke for his last 2 years of life. She has decided that, although she still enjoys life, lives independently and would like to have treatment for reversible conditions, she would not want to receive life-sustaining treatments, including CPR, ventilation or renal dialysis. She has explained her decision to her daughter who is supportive. TM visits her GP to ask how she can make sure that her wishes are known.

Show Intro
Start Quiz
Which of the following would be appropriate outcomes from this visit?
1 / 5
She sees a GP who completes a DNACPR form
Yes
No
2 / 5
She sees a GP who explains to her about ReSPECT, advance care planning and ADRTs, gives her an information leaflet and asks her to come back next week
Yes
No
3 / 5
She sees a GP who has a ReSPECT conversation with her and completes a ReSPECT form
Yes
No
4 / 5
She sees an advanced nurse practitioner who says that she can’t help her and tells her to book an appointment with a doctor
Yes
No
5 / 5
She sees a GP who tells her to make an appointment to discuss this with her daughter present
Yes
No
Go Back
A person having an intervention

Question 2

SCENARIO INTRO

Her GP completes a ReSPECT form with her, based on their conversation and shared decision-making about its content.

Show Intro
Continue
Which of the following are appropriate entries on her ReSPECT form?
1 / 6
Section 2: Daughter aware of her wishes
Yes
No
2 / 6
Section 3: Not being a burden to anyone
Yes
No
3 / 6
Section 4: Focus on life-sustaining treatment
Yes
No
4 / 6
Section 4: Active treatment for reversible illness (e.g. infection)
Yes
No
5 / 6
Section 4: Ventilation and renal dialysis not wanted
Yes
No
6 / 6
Section 6: A
Yes
No
Go Back
A person having an intervention

Question 3

SCENARIO INTRO

A few weeks later TM sees her GP as she has been experiencing blackouts and feeling dizzy. She is referred to a cardiologist. Investigations show that she has sinus node disease, and the cardiologist offers her pacemaker implantation. He explains that this is a minor procedure, carried out under local anaesthesia, and its purpose is to prevent further blackouts and dizziness that could result in injury or hospital admissions. She tells the cardiologist that she has already decided that she would not want ventilation, dialysis or CPR and shows him her ReSPECT form.

Show Intro
Continue
Which of the following should the cardiologist do?
1 / 4
Explain that cardiac arrest is a rare but recognised complication during pacemaker implantation but is usually rapidly reversible, and offer her the opportunity to reverse the recommendation about CPR during the procedure and immediate recovery period
Yes
No
2 / 4
Ignore the ReSPECT form and get on with implanting the pacemaker
Yes
No
3 / 4
Encourage her to discuss the new situation with her daughter
Yes
No
4 / 4
Refuse to go ahead with pacemaker implantation
Yes
No
Go Back
A person having an intervention

Question 4

SCENARIO INTRO

TM decides that she wants to have a pacemaker implanted and that she would like the recommendation about CPR, but not the recommendations about ventilation and dialysis, suspended during her day-case admission for this procedure.

Show Intro
Continue
What should be done with the ReSPECT form when she attends for pacemaker implantation?
1 / 4
Tell her to leave her ReSPECT form at home when she attends
Yes
No
2 / 4
Create a new ReSPECT form when she attends for pacemaker implantation, recommending CPR but not ventilation or dialysis, and tell her to keep the old form for use when she goes home
Yes
No
3 / 4
Create a new ReSPECT form when she attends for pacemaker implantation, recommending CPR but not ventilation or dialysis and cancel the existing form
Yes
No
4 / 4
On the existing form, cross out the signature in the ‘CPR attempts NOT recommended’ box and sign the ‘CPR attempts recommended’ box
Yes
No
Go Back
A person having an intervention

Question 5

SCENARIO INTRO

The pacemaker is implanted successfully and her pacemaker check is satisfactory. The cardiology registrar reviews her ReSPECT form with her and, with her agreement, cancels it and creates a new one that once again records her wish not to receive CPR, ventilation or dialysis, but to receive other treatments for reversible illnesses. She goes home with this form in late afternoon.

Shortly before midnight, she is brought to the Emergency Department (ED) by ambulance because of increasing left-sided chest pain and breathlessness. Clinical examination and chest X-ray show evidence of a left tension pneumothorax. The ED registrar wants to insert a chest drain. He is shown her ReSPECT form.

Show Intro
Continue
Which of the following statements is correct?
1 / 4
There is nothing to suggest that she has lost capacity, so he should seek her informed consent to emergency chest drain insertion
Yes
No
2 / 4
Pneumothorax is a recognised complication of pacemaker implantation, so her consent to pacemaker implantation automatically includes consent to treatment of complications
Yes
No
3 / 4
He should be cautious about inserting a chest drain as this is a life-sustaining intervention and she has recorded that she does not want CPR
Yes
No
4 / 4
Tension pneumothorax is a reversible illness so the ReSPECT form authorises him to go ahead with chest drain insertion
Yes
No
Go Back

Scenario Complete

TM has a chest drain inserted and is admitted to the cardiology ward. Her pneumothorax resolves and the chest drain is removed. The cardiology registrar reviews her ReSPECT form with her again before discharge and she is content that her previously agreed recommendations remain.
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A person lacking mental capacity

Question 1

SCENARIO INTRO

NF is an 84-year-old retired nurse. She has severe visual impairment, uses a hearing aid, and has vascular dementia. She has been living in a care home for 2 years. She relates well to the carers, and enjoys her meals and her daughter’s visits. Her daughter lives nearby and sees her at least weekly. Her son lives further away and visits every few weeks.

A community matron knows NF and her family well, and after confirming NF’s lack of capacity for decisions related to her health and future care, and recording that assessment in the health record, she has a ReSPECT conversation with the son and daughter. They tell her that their mother had given them Lasting Power of Attorney to make decisions for her.

Show Intro
Start Quiz
What further information does the community matron need?
1 / 5
What type of LPA do they hold?
Yes
No
2 / 5
Do they hold it jointly or individually?
Yes
No
3 / 5
Has it been registered with the Office of the Public Guardian (OPG)?
Yes
No
4 / 5
Does it include the power to decide about life-sustaining treatments?
Yes
No
5 / 5
Has NF made an Advance Decision to Refuse Treatment (ADRT)?
Yes
No
Go Back
A person lacking mental capacity

Question 2

SCENARIO INTRO

After clarifying this, the matron goes through the ReSPECT process with them, and completes a ReSPECT form with her agreed priority of care being to focus on comfort, and with agreed recommendations that she should be considered for admission to hospital for treatment of a reversible problem such as infection, but would not want to receive cardiopulmonary resuscitation or be admitted to an intensive care unit for treatments such as ventilation or renal replacement therapy.

6 weeks later, a carer finds NF lying on the floor moaning incoherently. The nurse in charge at the care home is called to help. When they attempt to move NF she screams and appears to be in pain. An out-of-hours GP attends and suspects that she has a fractured neck of femur.

Show Intro
Continue
What should the GP do?
1 / 5
Prescribe analgesia by injection?
Yes
No
2 / 5
Contact the son and daughter?
Yes
No
3 / 5
Read her ReSPECT form?
Yes
No
4 / 5
Infer from the recommendations that she should not be sent to hospital?
Yes
No
5 / 5
Dial 999 and send her to the nearest Emergency Department?
Yes
No
Go Back
A person lacking mental capacity

Question 3

SCENARIO INTRO

After speaking to her daughter (her son was not contactable) the GP arranges hospital admission with the orthopaedic team for treatment of her hip fracture.

Show Intro
Continue
When the ambulance arrives, which of the following is correct?
1 / 4
As the patient has a ReSPECT form, no other handover is needed.
Yes
No
2 / 4
The GP should be there to give handover personally.
Yes
No
3 / 4
The ReSPECT form should be kept at the care home in case it gets lost at the hospital.
Yes
No
4 / 4
The ambulance clinicians do not need to know what is on the ReSPECT form.
Yes
No
Go Back
A person lacking mental capacity

Question 4

SCENARIO INTRO

NF is seen in the ED by the orthopaedic registrar, sent for x-ray and transferred to the ward. On his ward round, the consultant confirms the diagnosis of fractured neck of femur and feels that hip replacement would be the most effective way of relieving pain and restoring mobility.

Show Intro
Continue
What should the consultant do?
1 / 4
Seek informed consent for surgery from the son and/or daughter.
Yes
No
2 / 4
Cancel her ReSPECT form in case she needs ICU care after surgery.
Yes
No
3 / 4
Refuse to operate unless her DNACPR recommendation is cancelled.
Yes
No
4 / 4
Discuss her treatment plan with the multidisciplinary team.
Yes
No
Go Back

Scenario Complete

The following day she has a left hip replacement. On the orthopaedic ward, she starts to mobilise slowly, and is transferred to a rehabilitation ward. There, she struggles to follow instructions from the physiotherapists. On checking her ReSPECT form, the physiotherapist realises that she is not wearing the hearing aid that is mentioned in section 2. On locating the hearing aid and fitting a fresh battery, she is able to follow the physiotherapist’s instructions much better. A week later, she is able to walk short distances using two sticks. Arrangements are made for her transfer back to the care home the following day. However, that evening, as she is walking to the toilet, she collapses on the floor and is found to be very breathless and cyanosed. The orthopaedic registrar is called, but before his arrival she becomes unresponsive and stops breathing. The nurses have all been trained in the use of ReSPECT, and allow NF to die with as much dignity as possible in the circumstances. The orthopaedic registrar arrives and tells them that they should have started CPR. They are upset by this, but the Senior Charge Nurse in orthopaedics supports their actions and reassures them. The Medical Examiner later reviews the circumstances of NF’s death, confirms that the nurses acted correctly, and arranges for the orthopaedic registrar to receive feedback and further training in the use of ReSPECT.
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A person with a chronic health condition

Question 1

SCENARIO INTRO

IA is a 65-year-old retired civil engineer from Bangladesh. He lives with his wife, who speaks little English, and two of his four children. He has a history of type 2 diabetes and reduced kidney function. Over the last twelve months his kidney function has deteriorated and he now has advanced kidney failure. He has had a previous heart attack, an episode of cellulitis in his right leg, and he is obese.

He is seen by his kidney specialist, accompanied by his wife. Dialysis is recommended, because of his advanced kidney failure, and he decides to have this treatment. The possibility of him being put on the list for a kidney transplant is also mentioned, but no firm decision is made about this.

Show Intro
Start Quiz
How could the ReSPECT process help IA at this time?
1 / 4
By ensuring that he understands his present condition and likely future progress
Yes
No
2 / 4
By recording his history of cellulitis in case of recurrence
Yes
No
3 / 4
By recording his preferences in case of a sudden complication during dialysis
Yes
No
4 / 4
By recording his wife’s communication needs in case of a future emergency
Yes
No
Go Back
A person with a chronic health condition

Question 2

SCENARIO INTRO

A dialysis nurse specialist tells Mr IA about ReSPECT and offers him an information leaflet, but he says that he does not want a leaflet or to discuss ReSPECT and have a form at present.

Show Intro
Continue
What should any health professional do if a person says that they do not want to discuss ReSPECT or have information about it?
1 / 5
Consider whether there are cultural or religious reasons for their decision
Yes
No
2 / 5
Consider whether they have any difficulty in understanding what has been explained, or in reading information in the format offered
Yes
No
3 / 5
Tell them that if they do not want to discuss ReSPECT, a form will be completed without their involvement
Yes
No
4 / 5
Record in their health record that they have been offered ReSPECT but do not want to discuss it yet
Yes
No
5 / 5
Respect their choice, but offer them opportunities to reconsider later, if and when they want to do that
Yes
No
Go Back
A person with a chronic health condition

Question 3

SCENARIO INTRO

IA starts regular dialysis and tolerates this well.

Six months later he has bad chest pain and is taken to the Emergency Department. After various tests, he is told that he has had a heart attack (non-ST-elevation myocardial infarction). He receives treatment in the Coronary Care Unit and an echocardiogram shows that the pumping action of his heart is severely reduced.

The cardiology registrar suggests that he reconsiders having a ReSPECT form, so that the nurses and other team members would know what to do if he had a sudden further problem with his heart and could not make decisions at the time. He decides that he would now like this.

Show Intro
Continue
Who may be best placed to start the ReSPECT conversation in this setting?
1 / 6
The cardiology registrar
Yes
No
2 / 6
The dialysis nurse specialist
Yes
No
3 / 6
A coronary care nurse
Yes
No
4 / 6
A consultant cardiologist
Yes
No
5 / 6
His GP
Yes
No
6 / 6
A palliative care consultant
Yes
No
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A person with a chronic health condition

Question 4

What preparation is essential for this ReSPECT conversation?
1 / 6
A formal assessment of his capacity
Yes
No
2 / 6
Finding a quiet room with comfortable seating
Yes
No
3 / 6
Ensuring minimal chance of interruption
Yes
No
4 / 6
Planning a date and time when all his family can be there
Yes
No
5 / 6
Knowing details of his condition and its treatment and prognosis
Yes
No
6 / 6
Discussion between cardiology and renal teams
Yes
No
Go Back
A person with a chronic health condition

Question 5

Which of the following are appropriate entries on his ReSPECT form?
1 / 4
Wife has limited English – speaks Bengali
Yes
No
2 / 4
Came from Bangladesh 10 years ago, to work as a civil engineer
Yes
No
3 / 4
NSTEMI – echo shows EF 16%
Yes
No
4 / 4
Has haemodialysis twice a week
Yes
No
Go Back
A person with a chronic health condition

Question 6

SCENARIO INTRO

The following day, during a meeting with his wife, his son, a Bengali interpreter, kidney and heart specialists, the clinical team explain that his current heart pumping efficiency limits his chance of having a successful kidney transplant. They explain that he can continue with dialysis and tablets to reduce the chance of rapid worsening of his heart condition. IA understands this, but nevertheless is content with his recent quality of life, and is clear that he wants his future care and treatment to focus primarily on sustaining life, including CPR if needed. This is agreed and recorded on his ReSPECT form.

The consultant explains that IA should take the ReSPECT form home with him, and keep it somewhere handy, making sure that his family know where it is kept and that they should show it to any health professional who is called in an emergency. He should take it with him when he goes for dialysis or other medical appointments. A few days later IA goes home.

Show Intro
Continue
When IA leaves hospital, which of the following is appropriate?
1 / 4
The discharge summary states that a ReSPECT form has been completed and sent home with him
Yes
No
2 / 4
The professionals involved in his discharge check that he understands and remains in agreement with the entries on the form
Yes
No
3 / 4
The ReSPECT form should be filed in IA’s hospital records
Yes
No
4 / 4
The discharge summary tells the GP to review the ReSPECT form as soon as IA arrives home
Yes
No
Go Back
A person with a chronic health condition

Question 7

What should the team advise him about taking his form with him?
1 / 4
Take it with him
Yes
No
2 / 4
Only take it with him if ReSPECT has been adopted in the locality where he will be
Yes
No
3 / 4
Leave it at home in case he loses it
Yes
No
4 / 4
Show it to the dialysis team when he arrives there for treatment
Yes
No
Go Back
A person with a chronic health condition

Question 8

How could they find out for him whether his ReSPECT form will be recognised and accepted whilst he is there?
1 / 5
Look it up on the NHS England website
Yes
No
2 / 5
Ask the staff at the dialysis unit where he will be treated
Yes
No
3 / 5
Telephone the Resuscitation Council (UK)
Yes
No
4 / 5
Tell IA to get his family to find out
Yes
No
5 / 5
Enquire via the ReSPECT website
Yes
No
Go Back

Scenario Complete

IA visits his family and attends the wedding and the dialysis sessions that were arranged for him. Whilst there, he shows his ReSPECT form to his elder brother, who has cancer of the prostate. Following this, his brother makes an appointment with his own doctor, to ask to go through the ReSPECT process himself.
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A person with an advanced terminal illness

Question 1

SCENARIO INTRO

AB is a 61-year-old lady who has been recently diagnosed with an advanced recurrence of pancreatic cancer. She lives with her husband, who is visually impaired; she is his full-time carer. Her husband is known to the social services team. She has no close family but has a network of friends.

Following three cycles of palliative chemotherapy, which she found very unpleasant, a repeat CT shows that the cancer is not responding. Her oncologist discusses the option of second-line chemotherapy, but she decides that she does not want to have this.

Show Intro
Start Quiz
Which of the following further actions may help her?
1 / 6
The oncologist tells her that nothing more can be done for her
Yes
No
2 / 6
She is offered referral to a palliative care team
Yes
No
3 / 6
She is guided through the ReSPECT process by a community nurse
Yes
No
4 / 6
Her GP completes a DNACPR form and telephones her to explain this
Yes
No
5 / 6
Her GP contacts her husband’s social worker
Yes
No
6 / 6
She is guided through a detailed advance care plan
Yes
No
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A person with an advanced terminal illness

Question 2

SCENARIO INTRO

AB’s oncologist discusses second-line chemotherapy, but she decides that she does not want to have this. He offers referral to the palliative care team, which she accepts, and he tells her about ReSPECT. She says that she would like to discuss it with her husband and her GP and takes home an information leaflet.

She visits her GP, accompanied by her husband, and is supported through the ReSPECT process and completion of her ReSPECT form. The GP suggests that she discusses a more detailed advance care plan with the palliative care team.

Show Intro
Continue
Which of these entries are appropriate in section 2 of her ReSPECT form?
1 / 6
Main carer for blind husband
Yes
No
2 / 6
Refused further treatment
Yes
No
3 / 6
Ca pancreas with hepatic and LN mets
Yes
No
4 / 6
Past history of carpal tunnel syndrome and left hip replacement
Yes
No
5 / 6
Cancer of pancreas, with spread to liver
Yes
No
6 / 6
Initial chemotherapy ineffective; does not want more
Yes
No
Go Back
A person with an advanced terminal illness

Question 3

SCENARIO INTRO

In the ReSPECT conversation, AB and her GP agree that her priority for care is maintaining comfort, and that what is most important to her is that her husband is cared for if she becomes too ill to help him. They agree also that CPR and admission to an ICU would not help her to achieve her goals of care. However, they agree that she would want to be considered for intravenous antibiotics and blood products if she needed these. All these recommendations are summarised in section 4 of her ReSPECT form. She is given the form to take home.

Show Intro
Continue
What should she do with her ReSPECT form?
1 / 5
File it away with her will in a binder on the bookshelf
Yes
No
2 / 5
Keep it handy
Yes
No
3 / 5
Tell her husband where to find it
Yes
No
4 / 5
Give it to her solicitor
Yes
No
5 / 5
Put it in her handbag when she goes shopping
Yes
No
Go Back
A person with an advanced terminal illness

Question 4

SCENARIO INTRO

Eight days later she wakes in the night shivering and sweating and feeling very ill. She calls an emergency ambulance.

Show Intro
Continue
What should the ambulance clinicians do?
1 / 5
Ask her if she wants to be taken to hospital
Yes
No
2 / 5
Read her ReSPECT form and follow the recommendations
Yes
No
3 / 5
Read her ReSPECT form before taking her to hospital
Yes
No
4 / 5
Leave her ReSPECT form with her husband for safe keeping
Yes
No
5 / 5
Call someone who can provide care for her husband
Yes
No
Go Back
A person with an advanced terminal illness

Question 5

SCENARIO INTRO

She is taken to the local Emergency Department, is found to have a chest infection and is admitted to the respiratory ward. The ReSPECT form is handed to the admitting nurse.

Show Intro
Continue
What should the nurse do with the ReSPECT form?
1 / 4
Show it to the admitting doctor
Yes
No
2 / 4
Read it and summarise its content at nursing handover
Yes
No
3 / 4
File it with the ambulance patient record form
Yes
No
4 / 4
Give it to the patient to keep in the bedside locker
Yes
No
Go Back
A person with an advanced terminal illness

Question 6

SCENARIO INTRO

AB improves with intravenous antibiotics. The hospital palliative care team are made aware of her admission and see her. Her main concern is her husband and who is looking after him at home whilst she is in hospital. The ward nurses contact his social worker and his GP surgery to alert them to his needs and ask them to ensure that he has all the help that he needs.

Seven days after admission, her abdomen becomes swollen and she starts vomiting. Scans show that she has small bowel obstruction. The surgical team are asked to see her.

The surgeon discusses with her the choice between ‘conservative treatment’ and surgery. She says that she does not want an operation, so is treated with intravenous fluids and nasogastric suction.

Show Intro
Continue
What else should the surgeon do?
1 / 5
Review the ReSPECT form with AB to agree whether to add a recommendation to avoid abdominal surgery to section 4
Yes
No
2 / 5
Tell the nurse to cancel the ReSPECT form as it’s out of date
Yes
No
3 / 5
Ignore the ReSPECT form and wait to see whether she responds to treatment
Yes
No
4 / 5
Ask the palliative care team to see her again
Yes
No
5 / 5
Arrange to see her husband
Yes
No
Go Back
A person with an advanced terminal illness

Question 7

SCENARIO INTRO

AB decides that she does not want any surgery, and this is added to section 4 of her ReSPECT form as an additional recommendation. The surgeon signs and dates section 9 to confirm the review.

Two days later her symptoms worsen. She is experiencing severe abdominal pain and she becomes confused. She is seen by another surgeon who wants to perform palliative surgery to try to relieve her symptoms. Because AB is now very confused, she does not have capacity to give informed consent.

Show Intro
Continue
What should the healthcare team do?
1 / 4
Show the surgeon the ReSPECT form and explain that AB made it clear that she did not want surgery and did not want ICU care
Yes
No
2 / 4
Ask her husband what he wants them to do
Yes
No
3 / 4
Obtain further help and advice from the palliative care team
Yes
No
4 / 4
Carry out a capacity assessment and document the findings in her health record
Yes
No
Go Back
A person with an advanced terminal illness

Question 8

SCENARIO INTRO

AB is seen by a member of the palliative care team, who also talks to her husband and to his social worker, and they agree that in her advance care planning discussions with the palliative care consultant she had said that she did not want to die at home as she thought it would be too distressing and difficult for her husband. They agree that transfer to the local hospice would be best for her, and in keeping with her wishes. A hospice bed and ambulance transport are arranged for later that day.

Show Intro
Continue
What should the healthcare team do about her ReSPECT form?
1 / 4
Leave it unchanged
Yes
No
2 / 4
Review it with her husband
Yes
No
3 / 4
Consider changing the previously recorded recommendations about antibiotics and blood products
Yes
No
4 / 4
Make sure that it stays in her hospital records when she leaves for the hospice
Yes
No
Go Back

Scenario Complete

AB’s ongoing care and treatment includes regular small doses of Oramorph to minimise distress from her cough and breathlessness, regular sips of water and regular mouth care. The following day she dies, with her husband and close friends at her bedside.
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A person with unexpected deterioration

Question 1

SCENARIO INTRO

RM is a 22-year-old student who is involved in a road accident. When the ambulance clinicians arrive, RM is unconscious, and they bring him to the nearest hospital. A member of the trauma team who examines RM in the Emergency Department finds paralysis of his left arm and leg and suspects several fractured ribs.

Despite treatment with oxygen, RM is becoming hypoxic and ventilation treatment is started. A CT scan shows a subarachnoid haemorrhage with a small amount of bleeding into the right side of the brain. He is transferred to the Intensive Care Unit (ICU) for continuing treatment. The neurosurgeons examine the CT images and recommend that RM is transferred to their neurological centre for further assessment and consideration of possible surgery.

RM’s parents attend the ICU and are devastated to see their son in these circumstances. The ICU consultant explains that their son may need an operation to reduce the effects of the bleeding into his brain, or to prevent further bleeding.

Show Intro
Start Quiz
When would be the best time to consider the ReSPECT process for RM?
1 / 5
Now
Yes
No
2 / 5
After transfer to the neurosurgical unit, when the prognosis will be clearer
Yes
No
3 / 5
When (if) RM regains consciousness
Yes
No
4 / 5
When (if) RM regains capacity
Yes
No
5 / 5
Only if and when RM or his parents ask for it
Yes
No
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A person with unexpected deterioration

Question 2

Who should be involved in the initial ReSPECT conversation for RM
1 / 5
The ICU consultant
Yes
No
2 / 5
An ICU nurse
Yes
No
3 / 5
RM’s parents
Yes
No
4 / 5
The local transplant coordinator
Yes
No
5 / 5
RM’s GP
Yes
No
Go Back
A person with unexpected deterioration

Question 3

What preparation is needed before the conversation?
1 / 4
The ICU consultant reads all the information on the ReSPECT website
Yes
No
2 / 4
The parents read the information leaflet
Yes
No
3 / 4
The ICU consultant and nurse discuss RM’s condition
Yes
No
4 / 4
Section 2 of the form is completed
Yes
No
Go Back
A person with unexpected deterioration

Question 4

SCENARIO INTRO

The ICU consultant explains to them that RM is very unwell. His condition could get suddenly worse and threaten his life. If he recovers, it is not certain whether he will be left with a disability due to brain damage from the bleeding. It is important that there is a plan in place to guide professionals faced with making an immediate decision about what is best to do for him in a sudden emergency.

After discussion, they reach a shared decision that there is still some possibility that he could make a good recovery, and the focus of care in an emergency should be on treatments that may help to sustain his life, including cardiopulmonary resuscitation. A ReSPECT form is completed, summarising these recommendations.

Show Intro
Continue
Which of the following should form part of the ReSPECT process and ReSPECT form for RM?
1 / 5
Decisions about the content of his form should be made in his best interests
Yes
No
2 / 5
His parents should be asked to decide whether he should receive CPR
Yes
No
3 / 5
A detailed assessment of RM’s capacity should be documented in his health records
Yes
No
4 / 5
His parents should be told that, as he is an adult, they have no say in his treatment
Yes
No
5 / 5
His parents are told that the form is legally binding
Yes
No
Go Back
A person with unexpected deterioration

Question 5

SCENARIO INTRO

The ICU doctors and nurses make sure that the ReSPECT form travels with RM to the neurological centre, that the ambulance clinicians have seen it and understand its content, and that the transfer letter tells the receiving clinicians that RM has a ReSPECT form. His transfer is uneventful.

On the neurosurgical high-dependency unit (HDU) the consultant and senior nurse read the ReSPECT form and agree to keep it under review in the light of RM’s progress. CT angiography shows an aneurysm as the cause of the bleeding requiring an operation to clip the aneurysm to reduce the risk of further bleeding. The neurosurgeon explains this to RM’s parents and that there is still a risk that he may not recover or that he will be left with some disability, and there is a small risk that the operation may lead to further brain damage. They agree that RM would want to go ahead with treatment to help him to try to recover. They discuss the ReSPECT form and agree that the entries are still correct.

Surgery is carried out and the aneurysm clipped as planned and RM is readmitted to the ICU. After a few days, the sedation is reduced and he is weaned from the ventilator, is able to breathe for himself, and he starts to speak. He is well enough to be transferred to the neurosurgical ward.

Show Intro
Continue
What should the neurosurgical team do about the ReSPECT form?
1 / 4
Cancel it as he is no longer at high risk of death or cardiac arrest
Yes
No
2 / 4
Ask his parents if they still want him to have it?
Yes
No
3 / 4
Explain it to RM and give him the chance to have a new form based on his personal preferences.
Yes
No
4 / 4
Leave it in place unchanged, as he is getting better and should still be for full and active treatment
Yes
No
Go Back

Scenario Complete

The neurosurgical registrar has a ReSPECT conversation with RM and confirms that he wants to be considered for all active treatment in the event of a sudden deterioration, and therefore that the current form remains valid. RM mentions that he would want to be an organ donor if he had a catastrophic illness with no chance of recovery. The registrar therefore amends the form to include this in section 2. Following rehabilitation over several weeks, he continues to improve and arrangements are made for RM to return home, with support from occupational therapists, physiotherapists, and social workers. He is given his ReSPECT form to take home.
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A young person with a chronic complex health condition

SCENARIO INTRO

Full scenario coming soon

Show Intro
Start Quiz
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Scenario Complete

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De-Brief

INTRODUCTION

Introduction

Whether you are leading the ReSPECT conversation or watching someone else, it is helpful to reflect on the conversation to help develop your practice. Learning from previous conversations will help to plan from future ones.

Following the conversation, it is good practice to debrief with a colleague who was present during the conversation or your supervisor/mentor. Having at least two perspectives enables on how the conversation went helps you to put together an accurate view of what happened and receive useful feedback.

Delete
Delete

The form below will help you facilitate the de-brief.

How do you feel the conversation went?

What went well? Which phrases were particularly effective?

What could be done better next time? Could anything have been phrased differently?

Was the desired outcome achieved?

How do you think the person (and/or those with them) perceived the conversation? Do you think they fully understood what was said?

What have you learned from this conversation?

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Preparation

INTRODUCTION

Introduction

Everyone is different in their approach and style for these conversations. You evolve your own style with time and experience. Just like learning a practical procedure, skills for having difficult conversations need to be practiced and it is helpful to reflect and listen to feedback.

The tool below is to help prepare for a ReSPECT conversation, you can save it to use before or during the conversation. It is important you anonymise any identifiable information regarding patients or those involved in their care.

Think about…

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Delete

Conversation reference

You may want to develop your own referencing system to identify saved conversations

Important considerations

When is best to have the conversation?

Where are you going to have the conversation?

How are you going to document and share the decisions?

Important people

Is there any information you can gather about the person in advance?

Who are you having the conversation with?

Who else should be in the room?

Who should lead the conversation?

Important questions

What is the purpose of the conversation?

How much information they want to receive?

What do they know already?

What are the possible wishes and priorites of the person?

What is the current and possible future clinical situation(s) and treatment(s)?

What would be a good outcome from the conversation?

Checklist for when in the conversation

This checklist may help you when in the conversation and will be added to the end of your saved preparation

Explain the purpose of the conversation

Establish how much information the person wants to receive

Establish what they know already

Establish where possible the priorities and wishes of the person

Explain the current and possible future clinical situation(s) and treatment(s) Summarise the conversation

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