where we came from, where we are & what’s next · where we came from, where we are &...
TRANSCRIPT
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
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!
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.
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.
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