Where we came from, Where we are & What’s next · Where we came from, Where we are & What’s next Dr. Zoë Fritz Chair of Strategic Steering Group for ReSPECT Consultant Physician,

Where we came from, Where we are & What’s next

Dr. Zoë FritzChair of Strategic Steering Group for ReSPECT

Consultant Physician, Acute Medicine, CambridgeWellcome Fellow in Society and Ethics

First, a reminder / recap:

ReSPECT

• DN….the acronym which loved to get longer• DNR

• DNAR

• DNACPR

• DNARUTIASRWACRC;AOTSBG

DNACPR – A few issues

ReSPECT

1. Not routinely completed (Cohn et al Q J Med 2013)

2. Inappropriate Resus Attempts (NCEPOD 2012 Time to Intervene)

3. No one likes discussing this (Sivakumar et al J Med Ethics 2004)

(So people didn’t) R (Tracey) v CUH NHS Foundation Trust & Ors [2014] EWCA Civ 822

4. Misunderstood (Fritz et al Resuscitation 2010)

DNACPR – and a couple more issues

ReSPECT

5. Difference in care (Chen JL, et al 2008, Cohen RI, et al 2009, Brizzi M, et al 2012, Kazaure

H, et al 2011, Moffat S et al 2016)

6. Variation in approach (Clements et al 2014 )

What to do about all of these problems?

ReSPECT

An ethical imperative to stop using DNACPR

But…Replace it with what?

And test it how?

Development of ReSPECT

ReSPECT

• Stakeholders from 37 different patient and clinical group

• review of evidence of best practice nationally and internationally

• UFTO, TEP, Deciding Right, the Unwell Patient, POLST, MOST

• 26 iterations via adapted Delphi method

• Public Consultation had over 1000 responses,

• 91% agreed with the principles

• Usability testing, 22 further iterations and change of title

• Further usability testing in 5 sites

• NIHR Grant to evaluate in early adopter sites

The ReSPECT Process— what’s involved

ReSPECT

1. Establish shared understanding of current situation

2. Discuss preferred outcomes

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j876

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j876

The ReSPECT Process— what’s involved

ReSPECT

1. Recommend treatments likely to result in these outcomes

2. Record recommendations in a readily recognised format.

3. CPR decision in context of overall goals of care

Change to ReSPECT — what’s needed?

ReSPECT

• A change of culture from:

• health and care professionals

• members of the public

Not just another change in acronym!

ReSPECT — who is it for?

ReSPECT

• Everyone, with increasing relevance for those: ▫ with particular healthcare needs ▫ nearing the end of their lives or at risk of cardiac arrest ▫ who want to record their preferences for any reason

• Best completed when a person is relatively well

• Can still ( obviously) be completed in an emergency if needed!

The past is prologue….

Website, Feb 2017

ReSPECT

www.respectprocess.org.uk

ReSPECT learning app, 2017

ReSPECT

Supporting Implementation

ReSPECT

• Catherine Baldock appointed as

ReSPECT Manager Sept 2017

• Implementation packs distributed

to more than 150 interested sites

• Support and outreach to sites

ReSPECT — process of adoption

ReSPECT

• ‘Responsibilities and requirements’ document • Governance

• Continued feedback

• Education across health care settings• Primary

• Secondary

• Ambulance services

• Care homes

• Hospices

Current and planned adoption

ReSPECT

Fully AdoptedCoventry and Warwickshire Dec 2016 includes UHCW and GEH Acute Trust, Warwick FT, CCG’s, Nursing Homes, Myton, WMAS

Heart of England Jan 2017 includes HEFT, Good Hope, Solihull, 2 CCG’s, WMAS

Manchester Central May 2017 includes Manchester Royal, Manchester Eye Hospital, Altrincham, St Mary’s and Trafford General

North & Mid Hampshire Sept 2017 includes CCG’s, hospices, Ambulance Service

Plans to adopt include: • 9 trusts and associated health care

communities with explicit ‘go live’ dates in 2018• 23 other trusts planning implementation• More than 70 others considering• 9 have decided to hold off.

Feedback essential…

ReSPECT — challenges to date

ReSPECT

• Section ‘6’ ( the discussion section) • simplified section developed and approved by lawyers,

to be piloted• Patient information leaflet

• simplified down to 1.5 pages• Audit tool

• being developed, will be available in Jan 2018• Digital…

ReSPECT - the digital challenge

ReSPECT

• Ideally we would like :• a universally accessible, smartphone friendly , intuitive digital solution that

interfaces with primary and secondary care ( as well as ambulance crews and hospices and care homes)

• And can be printable so the patient can have a copy at home• Which somehow links to and updates the electronic version

• But….• The NHS is NOT digitally integrated• No simple solution

• So….• 3 stages of development:

ReSPECT - the digital challenge

ReSPECT

1. A writable PDF (or Word Forms) document will be available early 2018

2. A standard template (digital archetype) for health care software engineers is being developed to integrate ReSPECT into other systems

3. Options are being explored for establishing a hosted service for ReSPECT data. - could potentially provide access to ReSPECT data from any EPR system

or via web interface/app to any authorised user. - This step presents significant challenge… - but the contained, discrete data set that ReSPECT represents may be a

good vehicle to deliver this.

What’s next?

ReSPECT

• Resuscitation Council (UK) has agreed to support continued development, education and evaluation as part of their strategic plan

• Implementation Network being developed : Jan 2019

• Education subgroup forming to develop further education materials including a stand-alone open-access module on the ReSPECT process

• Seminars and workshop planned London, April 2018 to share learning from early implementor sites and discuss future development

ReSPECT - what’s next?

ReSPECT - what’s next?

ReSPECT

ReSPECT is a dynamic process

• Developed in response to evidenced problems with DNACPR

• Driven by a desire to provide better care for our patients

• Dependent on continued engagement and feedback from those who are using it

ReSPECT — feedback please

Your feedback and engagement is crucial• join the implementation network• come to the meeting in April• email us

[email protected] or [email protected]… feel free to ask questions today!

Thank you

ReSPECT