The content discusses the Recommended Summary Plan for Emergency Care and Treatment (RESPECT) process, emphasizing its role as a communication tool for documenting and respecting patient preferences in emergency situations, and explores practical challenges and best practices for its implementation, particularly for paramedics.
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to hand you over to either tanya or emma
for an introduction to the respect process
process
so it's me tonight louise um thank you
very much so i'm in my husband's i'm one
of the partners of medicine consultants
in gloucestershire um and tanya is one
of the emergency medicine and priority
consultants so she said in the chat just
there um so next slide please
so we're here to talk about respect
we're here to talk about planning for
emergencies and we know that future
future care planning can help people to express
express
in advance of an emergency what matters
to them
how they would or how they wouldn't want
to live if something unexpected were to happen
happen
and i'm sure you're all familiar with
respect at this stage but respect stands
for recommended summary plan for
emergency care and treatment
and it's a process it's a process that
is supported by a form
but we emphasize that it is a process
rather than a piece of paper and it's
really about generating guidance that
can be used to inform decision making in
an emergency setting um often that's
relating to an underlying condition and
underlying illness but it might be a
very general statement particularly for
those who may be a bit more
globally frail without particular
illnesses um
alongside that
the goal is that it's created in
discussion with the individual and we've
been emphasizing very much today and in
these sessions that it is a process of
several discussions ideally um you want
to be having the conversation over time
and that can sometimes mean that you're
not going to be presented with a
completed form in a single episode and
that's obviously something that's
important from paramedic perspective
that you may have a quote unquote
half-completed form but the idea is to
create that joint understanding that
shared respect for somebody's
preferences what matters to them what
kinds of situations would they
potentially fear so for some people that
might be not wanting to be dependent on
others not wanting to be
artificially fed and unable to
communicate and for others they might
want to have all life-blooming
interventions as
much as it is reasonable for a zombies
as possible
and trying to be able to then shape any
guidance around treatment options that
are going to have the best chance of
fulfilling that individual's priorities
it's really
not just about cpr and actually the cpr section
section
is in many ways the the least important
part of that document around decision
making and how to look after somebody uh
in a situation of them becoming unwell
but that's clearly part of it and
certainly in gloucestershire it's now
the document that we use um as our
communication aid and
and
complete and hopefully to be able to
have a an ease of recognition for you as paramedics
paramedics
the hope is that by developing that
shared understanding we have clarity
over somebody's underlying health conditions
conditions
and we can get those realistic uh
clinical recommendations put down in
clear and and concise terms uh we know
that that's a work in progress with all
of the different groups of clinicians
who potentially can complete these documents
documents
and actually some of the feedback that
you guys give us is really helpful in
trying to
continually educate
and continually reinforce some of the
messages that we know we need to get to
it's a nationally recognized form it's
used in an awful lot of areas i think
over 100 areas have now adopted it so
it's something that you may well see in
other places and people bring you from
other locations and the other thing just
to note is it's not necessarily just for
adults we haven't formally adopted it in
gloucestershire for pediatrics yet but
it's coming
and it's very much been designed as an
all-age document so you will be seeing
this as something
that is part of advanced care planning
documents for pediatrics for kids um as
well as for adults going forwards
and i think that's about a reasonable
summary so to introduce ourselves to
this call into this particular patient
you are called to vera who is an 82 year
old lady who lives in gloucester these
are your initial call
details so you can see we're going to
vera williams she's an 82 year old lady
um she's in abu dale which is fairly
central in gloucester and we're being
called to her because she's feeling weak
as you arrive on scene this is vera's
house and this is what you see
you go through the open door that you
can see just to the bottom right of the
picture and an older man's voice called
you into the living room and here you
meet vera
she's on a bed in the front room and she
briefly opens her eyes when you say
hello but she quickly dozes off again
you ask what's happened today
at this point alph vera's husband tells
you that veer has been very tired today
fear is not herself and she's not been
talking much since
he can't get her to eat or drink
anything and he's quite worried about her
you ask queer if it's okay to check her
over and she agrees she opens her eyes
at that point your crewmate cracks on
with some observations and whilst you
ask alf about vera's past medical
history he mentions about her blood
pressure and her cholesterol but he's
not too sure at all and goes to get her
medications for you
and these are the medications that he
comes back with fear has got a bit of
nitrofurantoin a bit of a talk for
statin some ramapril some paracetamol
elf says that there has been having her
usual trouble with her waterworks again
and you have a little look at the
summary care record on the epcr which
mentions recurrent uti but it doesn't
really have very much else on there
elf also mentions that they have carers
in twice a day and during your hunt
around the house you spy a care notes folder
and just creeping out the top of that
care notes folder you can see the corner
of a purple respect form which is
sticking out and you start to have a
little bit of a look through the details
so you can see that the form has vera's
name on it it has her date of birth it
has her address it has her preferred
name it has the date that it was completed
completed
you've got a little bit more information
on her medical history which is
consistent with the medications that
you've seen so on top of the current
recurrent utis she's got some
hypercholesterolemia some arthritis
she's had a stroke previously some
hypertension and a mild onset of
dementia and at the moment there aren't
any other decisions or
such as advanced participation care
plans advanced decisions to refuse
treatment advanced directives and
you carry on down the form
and you can see that it's really
important to vera that she balances
sustaining life with dignity and comfort
and she's very very worried about being
potentially being in pain or losing her
independence and would like to not be in
pain and to promote being independent
for as long as possible
in terms of the clinical recommendations
she'd like to balance extending her life
with comfort and with valued outcomes
and she'd prefer to be treated at home
if that's an option
she has said she would consider going to
hospital if treatment at home was not
possible or if it was ineffective but if
she does go into hospitals she's for a
full active ward-based ceiling of care
and vira would not like to have cpr
mira had capacity when she was making
these decisions so she was actively
involved within this decision making
and she has said that this is what she
would like to happen should she deteriorate
so at this point you perform an ask and check
you ask
i can see that vera doesn't wish to go
to hospital if she can be treated at
home and wants to be as comfortable as
possible is that still correct
and you check that this is the most
up-to-date copy of the form with alf you
ask alf has anything changed recently
but at this point your crewmate has now
finished all the observations and comes
back with the following so you've got
your temperature your blood pressure
your sats and your heart rate and your
blood glucose on there
the crewmate has also done a bit of an
assessment of vera and they have found
that vera's chest is clear and she has
no obvious rashes or breaks in her skin
her abdomen was fairly soft but she did
have some mild generalized discomfort on
a bit of palpation and this is
vera's ecg for those of you that enjoy
an ecg we'll give you a moment just to
i'll just give you another 30 seconds or
so to have a little look at that ecg
so you take all of these elements into
consideration you start to have a think
about what we're going to do with vera
and at this point you consider vera's
case and decide that she probably needs
different antibiotics and some fluids
for a potential exacerbation of her
recurrent utis
you have a think about all the possible
options for vera in your area and you
weigh up the benefits of hospital
admission and your available community services
services
deciding that based on her history her
presentation her observations and her
respect guidance that the best course of
action is to speak to her community
outreach team
you decide to consult the community
outreach team to see if they can provide
the supportive care you think the vera needs
needs
alpha agrees with this plan and you're
just finding the number to call them
when fear is family appears
you explain the plans in virus family
but they aren't happy and they demand
that you take there to hospital at this point
so at this point we're going to move
over to you and your thoughts on this
situation we're going to go into some
breakout rooms we're going to have some
discussion around these four questions
so we're going to consider would you
feel different if the case involves cpr
recommendations we'll talk about the uh
processes and procedures you may follow
at this point and we'll work through the
other questions around what we're going
to do with other healthcare
professionals and other sources of
information so we're going to move into
breakout rooms at this point
so first up should i talk about our room
uh whilst i have the microphone and then
i'll pass on to somebody else um so
first up we were talking about what
would we we would do in this situation
with the conflicts between the family um
and with what the patient's wishes
potentially would be and we had a really
good question actually just right at the
end that snuck in under the radar around
should the patient's wishes override
everything else and i kind of want to
bring emma and tanya in on this one as
well because i feel quite strongly that
we should be advocating for them and
should be respecting their wishes but
would you agree with that perspective or
are there any situations where you'd say
actually maybe that's not what we go
with so i think it's about the subtlety
between wishes and demands
um no patient can demand an intervention
that isn't felt to be appropriate and
that's a subtly different thing to
respecting somebody's wishes so somebody
being able to say to you i want you to
do everything i want you to put me on a
machine i want you to breathe for me i
want you to keep my brain in the jar for
eternity until uh i can be regenerated
and believe it or not i have had that
conversation with somebody um it is is an
an
unrealistic and
an and inappropriate demand but somebody
being able to say look i talked about
wanting to stay at home i don't want to
actually now i feel like i don't feel
safe here i want to go to hospital um
that's okay to be able to revisit that
and i think that's a really key part of
respect is it's not set in stone and
people can change their minds it's not
always easy to if it says not for hospital
hospital
they don't necessarily feel that you
can't take somebody to hospital if
that's the right thing to do but it's
just that subtlety of patient wishes
versus demands um the point of respect
is mutual respect their priorities
clinical recommendations they don't
always completely marry but if somebody
wants everything doing you can do
everything that's reasonable and that
doesn't necessarily include absolutely
everything every type of intervention
that's out there
i think it's also very important to
try and explore what patients fish
wishes are because for example you often
get people that say my wish is always to
be resuscitated but when you dig down on
something they don't mean cpr they mean
they don't want you to leave them in a
corner just to die when there's
something that you could do that would
be reasonable and you can take that to
all all
you know all points they might say i
don't ever want to go to hospital but
what they mean is they don't want to be
on an ed corridor and that's very
reasonable and you might find the way
around things so it's always about exploring
exploring
what's important to people and their values
lovely thank you very much in terms of
making sure that we um ensure we are
upholding those wishes and exploring
this it's a real key theme of
communication that runs through all of
our answers for all of the the different
questions that we asked when we talked
about talking with the family there's a
strong theme in our room around
understanding of the family and family perspective
