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 this kind of shared understanding (see appendix 1). The ReSPECT process provides a framework to ensure that conversations about future care planning begin with the person’s values and priorities, leading on to recommendations about care and treatment. The practice of future care planning is not new, but existing processes leave a significant gap in communicating a person’s values effectively enough to guide decisions about care in an emergency.

Ayrshire and Arran’s Healthcare Governance Committee gave approval in April 2023 for ReSPECT to be adopted as part of our strategic commitment to better care towards the end of life, across all relevant health and social care settings, subject to the appropriate site-specific training.

ReSPECT lets healthcare staff know what matters to the person when in a health crisis who may not be able to speak up for themselves. Once the plan is completed, professionals such as ambulance crews, out of hours health professionals, care home staff and hospital staff will be better able to make immediate decisions about a person’s emergency care and treatment.

Purpose

The aim of this document is to outline the standardised approach for creating ReSPECT plans in partnership with people and those close to them through the digital ReSPECT web application. This applies to all registered patients of NHS Ayrshire & Arran.

ReSPECT will be offered through a variety of settings including GP surgeries, hospitals, Ayrshire Hospice, HMP Kilmarnock and within homes (including care homes)

Scope

This Standard Operating Procedure will provide a basis 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.

The aim of our training material is to help health and social care professionals listen better to understand what matters to people in a health emergency. NHS A&A ReSPECT Learn-pro module completion is required for all active users of the ReSPECT web application.

The ReSPECT competency framework should be used to review health professionals’ knowledge and skills in preparation for carrying out these future planning conversations (see appendix 2).

System access

ReSPECT is AD integrated therefore account permissions will be managed within Active Directory by the Systems Access Team, Digital Services NHSAA. Temporary staff end date is recorded on form and permanent leavers are updated in the HR (Human Resources) leavers list and subsequently removed by Digital Services System Access Team.

Users will complete a system access request using form 1 (Request New IT Account or Access to Clinical System) within the Service Now platform and attach the signed form. This is accessible through the following process: Home > Service Catalogue > Digital Services > System Access Request > View Details > Form 1.

Requesting systems access for the ReSPECT web application

Users have been advised that upon completion of the above process they will gain access to the permissions with authorised line manager approval. Users must complete the required Learn Pro/Training prior to access requests being submitted. Once access is approved the user will receive a confirmation of access email, with log in details – these will be the same as PC log in.

For users who have completed the step above (system access) and have confirmation, you will now be able to log into the ReSPECT application. The Clinical eHealth links on the front page of Athena provide a shortcut to this web application.

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 cardiopulmonary resuscitation (CPR)) won’t help. 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 too much treatment. 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 emergency, especially if otherwise they may not get the care that is right for them.

Web based information

ReSPECT information for health professionals can be found within the Person Centred Care section of Athena and public facing information can be sourced from the Ayrshire and Arran public website: https://www.nhsaaa.net/services/services-a-z/respect/

Leaflets

Leaflets have been developed to support information for the public. These will also provide helpful information for professionals (see appendix 3 under Related NHS Ayrshire & Arran documents below). These will be subject to review in response to testing and feedback.

Questionnaires

Receiving feedback is crucial to inform future service development. A QR code supporting feedback has been added to the public leaflet but for people who would require a paper copy, the health professional completing the ReSPECT plan should arrange for a paper questionnaire to be supplied. These 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.

Even when a person’s capacity is impaired, it will usually be possible to get an idea about what they would most value and what they most fear. We can involve them as much as they are able and willing and gather the insights of family or friends about them as a whole person.

• If a person has temporarily lost capacity because they are ill, it will usually be best to defer making a ReSPECT plan until they haverecovered.
• If a person regains capacity after a ReSPECT plan is created, it is essential that it is reviewed with them at the earliest opportunity.

The plan is created through conversations between the person and the health professional involved in their care. The ReSPECT conversation between the person and their health professional includes the following:

• A shared understanding of the person’s current state of health and how it may change in the foreseeable future.
• Identifying what is important to the person in relation to goals of care in the event of a future emergency.
• Record the agreed priorities for care (e.g. more towards life sustaining treatments or more towards prioritising comfort over efforts to sustain life)
• Making and recording shared recommendations about specific types of care and treatment that would or would not be of overall benefit to them and explaining sensitively recommendations about treatment that would not help.
• Making and recording a shared recommendation about whether or not CPR is recommended.

All ReSPECT plans in NHS Ayrshire & Arran will be 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.

Recording ReSPECT plans in GPIT systems

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) – Appendix 4

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.

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

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 Information Summary.

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.

ReSPECT plan PDFs are available in the document tree within Clinical Portal, and a summary should be made available on the Key Information Summary as outlined above. GP practices will have a link via Docman.

ReSPECT conversations 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.

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 report quarterly into the Person Centred Care Network, and thereafter into the Health, Safety and Wellbeing Committee.

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.

Related NHS Ayrshire and Arran documents

Appendix 1: Link to ReSPECT plan ReSPECT Blank Specimen Form - Draft Copy.

Appendix 2: ReSPECT competency skills framework 

Appendix 3: ReSPECT Leaflets:

• Listening to put you at the heart of your emergency healthcare ReSPECT.
• Living with ReSPECT. Keeping what matters to you at the heart of your emergency healthcare.

Appendix 4: NHS AA Recording ReSPECT Plans in GPIT Systems.

References

Resuscitation Council UK. ReSPECT

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