ReSPECT - recommended summary plan for emergency care and treatment. Standard operating procedure

Many people approaching the end of life undergo emergency medical interventions and hospitalisations that do not hold value for them. This could be avoided if healthcare professionals understood the person’s priorities and values as expressed in advance of a healthcare emergency.

The national Recommended Summary Plan for Emergency Care and Treatment (ReSPECT), developed by the Resuscitation Council UK provides an opportunity to guide shared decision making in this context (see appendix 1). ReSPECT provides a framework for conversations about future care planning based on a shared understanding of the person’s health outlook, their values and priorities, and creates clinical recommendations about emergency care and treatment. ReSPECT is communicated electronically across care settings.

Ayrshire and Arran’s Healthcare Governance Committee supported the adoption of ReSPECT in April 2023 as part of our strategic commitment to better care towards the end of life.

Purpose

This document outlines the standardised approach for creating ReSPECT plans in the digital ReSPECT web application and applies to all registered patients of NHS Ayrshire & Arran in all care settings.

Scope

This Standard Operating Procedure will provide a guide for clinical and administration staff employed by NHS Ayrshire & Arran to assist in the completion of ReSPECT plans.

Definition of terms

AD - Active Directory

NSS - National Services Scotland

ReSPECT - Recommended Summary Plan for Emergency Care and Treatment.

In a health emergency, healthcare professionals need to know what matters to the person who is ill. If they don’t, they may make treatment decisions based on incomplete information or inaccurate assumptions.

Some people may be at risk from too little treatment if the healthcare team wrongly conclude that treatments (like hospital care or CPR) won’t be of benefit. This may be a particular risk for people who live with disabilities and people who experience social or economic exclusion.

Some people are at risk of receiving treatment that will not benefit them. They may not prioritise “life at all costs”, either because there is a minimum quality of life they would find acceptable, or because there is a limit to what they would be prepared to go through for the chance of living longer.

A ReSPECT plan can be offered to anyone who wants to make their values and priorities clear to healthcare professionals. ReSPECT will make the most difference to people at increased risk of a health crisis, especially if otherwise they may not get the care that is right for them.

Training materials address the professional knowledge, skills and attitudes required to understand the purpose and support the practice of ReSPECT.

• NHS A&A ReSPECT Learn-pro module: available for all users and mandatory for staff new to future care planning.
• NHS Learning Hub: ReSPECT essentials e-learning: Promoting person centred planning and emergency care
• NHS A&A CONnECT: Conversations about Emergency Care and Treatment Skills based practice
• Workshops, events and other learning opportunities may be arranged on request from aa.respect@aapct.scot.nhs.uk

A detailed ReSPECT competency framework is available and must be reviewed by teams new to future care planning (see appendix 2).

System access

ReSPECT is AD integrated and account permissions for Read/ Write access will be managed within the Active Directory by the Systems Access Team, Digital Services NHSAA. Read/ Write access is requested via the Digital Service Desk by line managers on behalf of a team or an individual.

Registered medical staff are expected to possess the core competencies for future care planning and will be granted Read/ Write Access as a professional group. Training specific to ReSPECT is available to all staff and is included in induction learning for medical staff joining the organisation.

Individual GP practices are responsible for keeping the list of active users up to date with NHS digital services.

Other healthcare professional groups must confirm mandatory training (ReSPECT LearnPro module or equivalent) prior to requesting systems access. As a minimum, all non-medical staff and those new to future care planning must complete ReSPECT LearnPro module or equivalent.

Requesting system access for the ReSPECT web application

Users who have completed the step above (requesting system access - see appendix 5) and have confirmation can securely access the web application at https://respect.products.ndp.scot/. This link is available from the Athena ReSPECT page, can be saved as a shortcut or launched from within a patient record in Clinical Portal, under the <More> tab.

Access to the web application is not required for Read only access. Existing ReSPECT plans may be viewed on <Clinical Portal> <Care Plans> < ReSPECT>, or on Docman on GP systems.
ReSPECT is also visible on the Electronic Care Summary (ECS) and Adastra.

Electronic versions of ReSPECT receive automatic updates. Any pdf paper copy or transcribed summary must be kept up to date. For patient-held paper copies, this is the responsibility of the healthcare professional who updates the plan. Any healthcare team using a paper copy other than that held by the patient is responsible for having a clear process in place to ensure that the copy in use is the most up to date.

Web based information

Local ReSPECT information for health professionals can be found NHS Ayshire & Arran intranet Athena and public facing information can be sourced from the Ayrshire and Arran public website: https://www.nhsaaa.net/services/services-a-z/respect/. 

National resources are maintained by the Resuscitation Council UK.

Leaflets

Leaflets for the public are available from aa.respect@aapct.scot.nhs.uk. These will also provide helpful information for professionals (see appendix 3).

Questionnaires

Feedback is required to inform future service development. A QR code supporting feedback has been added to the Living with ReSPECT follow up leaflet, survey at: https://www.smartsurvey.co.uk/s/NHSAA_ReSPECTpatientsurvey/ and paper copies are available on NHS AA public website and Athena. Feedback can also be sent by email (see below).

Mailbox management

Enquiries relating to ReSPECT will be directed to and managed via the shared mailbox: aa.respect@aapct.scot.nhs.uk.

Verbal consent must always be obtained prior to the completion of any ReSPECT plan. Public leaflets are available and should be offered in advance of ReSPECT conversations. Information on confidentiality is included here.

When a person’s capacity for making decisions about their care is impaired, it will usually be possible to get an idea about what they would most value and what they most fear. People should be involved as much as they are able, and the insights of family or friends about them as a whole person should be used to guide their ReSPECT plan.

• If a person has temporarily lost capacity because they are ill, it may be best to defer making a ReSPECT plan until they have recovered.
• If a person regains capacity after a ReSPECT plan is created, it is essential that it is reviewed with them at the earliest opportunity.
• If a person lacks capacity, a ReSPECT plan may be made in partnership with their proxy or those closest to them.
• ReSPECT plans should not be imposed on a person who does not want one (or if they lack capacity and the proxy/ person closest to them does not want).

The plan is created through conversations between the person (or their nearest carer/representative if they lack capacity) and a health professional involved in their care, as well as family or friends nominated by the patient. ReSPECT conversations cover:

• A shared understanding of the person’s current state of health and how it may change in the foreseeable future.
• What is important to the person in relation to goals of care in the event of a future emergency.
• Agreed priorities for care (e.g. more towards life sustaining treatments or more towards prioritising comfort).
• Recommendations about specific types of care and treatment that would or would not be of overall benefit to them.
• A recommendation on the benefit of CPR (i.e. includes recommendations against CPR/DNACPR if appropriate)

ReSPECT plans are completed electronically using the ReSPECT web application developed by NES Technology Service and hosted on the National Digital Platform. A printed PDF copy of the plan should be offered to the person or carer to keep at home.

If healthcare teams use additional downloaded PDF versions of their patients’ ReSPECT plans, they must make sure they have processes in place to keep these up to date. Wherever practicable, staff should refer to the electronic version which will be automatically updated following any revisions.

Any future reviews/changes to the ReSPECT plan will follow the above process ensuring only the most up to date plan is within the person’s possession and their records.

ReSPECT plan PDFs are exported automatically to the document tree within Clinical Portal under <Care Plans>; to the Electronic Care Summary (ECS), Adastra and to GP practices via Docman. There is no direct electronic import into the Key Information Summary and GP practices may consider updating the KIS accordingly.

A Trak Care Alert to the presence of a ReSPECT plan is added manually within a week or two by the ReSPECT and Health Records teams and is visible on Clinical Portal.

At transitions of care, ReSPECT plans may also be highlighted, e.g. within the ‘Future Care Planning’ section of the Immediate Discharge Letter. Within the ReSPECT web application, there is a function to <Copy Summary> which can be then be pasted into a relevant document such as a discharge letter or Key Information Summary. Care must be taken to update this if the ReSPECT plan is updated.

Detailed guidance for recording ReSPECT plans in GP IT systems is included in Appendix 4 and in the next section below

Plans authored using the digital application can be viewed directly on the application itself or as a two page ‘PDF’ document. When a plan is published, the application will automatically send a copy of this PDF to the patient’s General Practice using Docman Electronic Document Transfer (EDT) to be processed by the practice and filed into the patient’s record. The codes and advice provided here are suggestions intended to be helpful but are not mandated by any policy at this time.

Configuring Docman to file the plans (NHS A&A Guidance)

It is advisable to configure Docman filing to ensure each plan is saved correctly. Within Docman – Settings – Maintain Lists – Lists - Departments – Add Item – In the Description Field enter Future Care – In the Folder field chose Administration. Leave the Search Code field blank Choose F12 Save

Which terminology is being used?

GPIT systems (EMIS and Vision) in use in Scotland use mapped implementations of SNOMED CT. They were originally Read Code systems, but now employ local codes in their interfaces which are mapped to SNOMED CT internally. To users the applications look like they are using Read Code or Local Code browsers, rather than a SNOMED CT browser.

Specific concepts for ReSPECT are available in the UK Edition of SNOMED CT but these are not available at this time (May 2023) in the versions of EMIS or Vision deployed in Scotland. Requests are being processed for adding the new SNOMED CT concepts to Vision and EMIS. This document describes the use of proxy codes available in the Read Codes which can be used in the interim. This is not ideal, but practices may find it a useful approach in the medium term.

Should we record terminology codes for this purpose?

Plans received or created by the practice should be added to the patient’s document record in Docman. When a ReSPECT plan is received via EDT or scanned into the Document Record, we do not advise that you set the coding element with Docman but instead manually code within the patient record within EMIS or to give an indication that a ReSPECT plan is in place. Practices may also wish to add a specific coded entry in the GPIT system to indicate the presence of a ReSPECT plan. It is good practice, where resources allow, for practices to create or update the Key Information Summary GP Special Note with the ReSPECT summary text. Users with ReSPECT web access can copy and paste directly from the ReSPECT web application into KIS. When using this function users must take care not to inadvertently overwrite existing KIS text. It is also advisable to check and update any other areas of the KIS as required

How do you add these codes?

At this time practices that wish to do so will need to manually add a Code for this purpose and configure Docman to use a specific code for ReSPECT plans. In due course, for ReSPECT plans received via Docman Electronic Document Transfer (EDT), it should be possible for a default SNOMED CT concept to be provided as part of the usual Docman filing processes

Which codes should you use?

Adding a Plan: When filing the ReSPECT plan into Docman and the associated code in the GP record we recommend you use:

• 8CM. Care plan
  For making an entry in the patient record to indicate that the patient has a ReSPECT plan we recommend you use:
• 8CMd. Emergency health care plan
  With free text of ‘ReSPECT plan’.
  Entries with a code of ‘8CMd.’ are included by default in the Key InformationSummary.

Removing a Plan: In common with other care plan codes, there is no specific code to use if the patient no longer has a ReSPECT plan. The original record will remain correct as it was correct at the date and time of entry so should not be deleted.
The original entry can be amended with free text to indicate that the ReSPECT plan has been inactivated or withdrawn. For example:

• 8CMd. Emergency health care plan
  With free text ‘ReSPECT plan active from date of entry until*date_of_inactivation*.
  If a new plan is started or the original one is re-activated then a new entry of ‘8CMd.’ should be made.

NHS Ayrshire & Arran December 2023 v1.1 Edited from National Document - Recording ReSPECT Plans in GPIT Systems

ReSPECT conversations may involve complex and emotionally challenging work. Protected time for reflection will nurture staff in their continuous development of good knowledge, skills and values. Regular, high quality and supportive supervision will be key to this process. The ReSPECT competency framework, review of completed ReSPECT plans and feedback from patients and family members may all contribute to this learning and development. Participation in ReSPECT training also provides an opportunity for staff support.

Reporting mechanism

NHS Ayrshire and Arran will receive weekly activity reports from NSS (National Services Scotland). These reports will be analysed regularly to inform future developments ensuring a continuous improvement focus.

Governance

The ReSPECT steering group will submit quarterly reports to the Medical Clinical Governance Group and thereafter into the Acute Services Clinical Governance Steering Group. Other acute services divisional governance groups will receive occasional and on-request summary reports.

Each of the Health and Social Care Partnerships with significant participation in ReSPECT will receive at least annual reports to their Health and Care Governance Groups.

NHS A&A Person Centred Care Network receive reports on request.

NHS A&A Healthcare Governance Group receive reports on request.

Service Level Agreement with NES Digital Services

A service level agreement is in place between NES Digital Services and NHS A&A Digital Services. It is available from either the ReSPECT steering group or local Digital Services.

Technical issues with the ReSPECT web application or with its integration with local IT systems may be escalated by the local IT team or ReSPECT steering group to the NES Digital ReSPECT Service Desk: NES Digital ReSPECT Service Desk.

Resuscitation Council UK. ReSPECT

NHS Ayrshire & Arran ReSPECT mailbox: aa.respect@aapct.scot.nhs.uk