1
|
Underwood M, Noufaily A, Blanchard H, Dale J, Harlock J, Gill P, Griffiths F, Spencer R, Slowther AM. GPs' views on emergency care treatment plans: an online survey. BJGP Open 2024:BJGPO.2023.0192. [PMID: 38191186 DOI: 10.3399/bjgpo.2023.0192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/26/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND A holistic approach to emergency care treatment planning is needed to ensure that patients' preferences are considered should their clinical condition deteriorate. To address this, emergency care and treatment plans (ECTPs) have been introduced. Little is known about their use in general practice. AIM To find out GPs' experiences of, and views on, using ECTPs. DESIGN & SETTING Online survey of GPs practising in England. METHOD A total of 841 GPs were surveyed using the monthly online survey provided by medeConnect, a market research company. RESULTS Forty-one per cent of responders' practices used Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) plans for ECTP, 8% used other ECTPs, and 51% used Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms. GPs were the predominant professional group completing ECTPs in the community. There was broad support for a wider range of community-based health and social care professionals being able to complete ECTPs. There was no system for reviewing ECTPs in 20% of responders' practices. When compared with using a DNACPR form, GPs using a ReSPECT form for ECTP were more comfortable having conversations about emergency care treatment with patients (odds ratio [OR] = 1.72, 95% confidence interval [CI] = 1.1 to 2.69) and family members (OR =1.85, 95% CI = 1.19 to 2.87). CONCLUSION The potential benefits and challenges of widening the pool of health and social care professionals initiating and/or completing the ECTP process needs consideration. ReSPECT plans appear to make GPs more comfortable with ECTP discussions, supporting their implementation. Practice-based systems for reviewing ECTP decisions should be strengthened.
Collapse
Affiliation(s)
- Martin Underwood
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire, Coventry, UK
| | | | | | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jenny Harlock
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Paramjit Gill
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Rachel Spencer
- Warwick Medical School, University of Warwick, Coventry, UK
| | | |
Collapse
|
2
|
Eli K, Harlock J, Huxley CJ, Bernstein C, Mann C, Spencer R, Griffiths F, Slowther AM. Patient and relative experiences of the ReSPECT process in the community: an interview-based study. BMC Prim Care 2024; 25:115. [PMID: 38632508 PMCID: PMC11022317 DOI: 10.1186/s12875-024-02283-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 01/19/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) was launched in the UK in 2016. ReSPECT is designed to facilitate meaningful discussions between healthcare professionals, patients, and their relatives about preferences for treatment in future emergencies; however, no study has investigated patients' and relatives' experiences of ReSPECT in the community. OBJECTIVES To explore how patients and relatives in community settings experience the ReSPECT process and engage with the completed form. METHODS Patients who had a ReSPECT form were identified through general practice surgeries in three areas in England; either patients or their relatives (where patients lacked capacity) were recruited. Semi-structured interviews were conducted, focusing on the participants' understandings and experiences of the ReSPECT process and form. Data were analysed using inductive thematic analysis. RESULTS Thirteen interviews took place (six with patients, four with relatives, three with patient and relative pairs). Four themes were developed: (1) ReSPECT records a patient's wishes, but is entangled in wider relationships; (2) healthcare professionals' framings of ReSPECT influence patients' and relatives' experiences; (3) patients and relatives perceive ReSPECT as a do-not-resuscitate or end-of-life form; (4) patients' and relatives' relationships with the ReSPECT form as a material object vary widely. Patients valued the opportunity to express their wishes and conceptualised ReSPECT as a process of caring for themselves and for their family members' emotional wellbeing. Participants who described their ReSPECT experiences positively said healthcare professionals clearly explained the ReSPECT process and form, allocated sufficient time for an open discussion of patients' preferences, and provided empathetic explanations of treatment recommendations. In cases where participants said healthcare professionals did not provide clear explanations or did not engage them in a conversation, experiences ranged from confusion about the form and how it would be used to lingering feelings of worry, upset, or being burdened with responsibility. CONCLUSIONS When ReSPECT conversations involved an open discussion of patients' preferences, clear information about the ReSPECT process, and empathetic explanations of treatment recommendations, working with a healthcare professional to co-develop a record of treatment preferences and recommendations could be an empowering experience, providing patients and relatives with peace of mind.
Collapse
Affiliation(s)
- Karin Eli
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK.
| | - Jenny Harlock
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Caroline J Huxley
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Celia Bernstein
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Claire Mann
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Rachel Spencer
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Frances Griffiths
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Anne-Marie Slowther
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| |
Collapse
|
3
|
McCallum K. Overcoming the barriers to optimal end of life care in the emergency department. Emerg Nurse 2023:e2170. [PMID: 37667653 DOI: 10.7748/en.2023.e2170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 09/06/2023]
Abstract
The focus of care in the emergency department (ED) is on saving or sustaining life, but some patients admitted to the ED die in the ED. Nurses whose focus is on saving lives may therefore find themselves providing end of life care to patients and their families in a stressful and distressing environment. Providing optimal end of life care involves reflecting on what a good death looks like and how patients can be supported to have a good death. This article describes the barriers to optimal end of life care in the ED and prompts nurses to think about how they can enhance their practice when caring for dying patients and their families.
Collapse
Affiliation(s)
- Kay McCallum
- acute oncology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| |
Collapse
|
4
|
Warner BE, Lound A, Grailey K, Vindrola-Padros C, Wells M, Brett SJ. Perspectives of healthcare professionals and older patients on shared decision-making for treatment escalation planning in the acute hospital setting: a systematic review and qualitative thematic synthesis. EClinicalMedicine 2023; 62:102144. [PMID: 37588625 PMCID: PMC10425683 DOI: 10.1016/j.eclinm.2023.102144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/18/2023] [Accepted: 07/24/2023] [Indexed: 08/18/2023] Open
Abstract
Background Shared Decision-Making (SDM) between patients and clinicians is increasingly considered important. Treament Escalation Plans (TEP) are individualised documents outlining life-saving interventions to be considered in the event of clinical deterioration. SDM can inform subjective goals of care in TEP but it remains unclear how much it is considered beneficial by patients and clinicians. We aimed to synthesise the existing knowledge of clinician and older patient (generally aged ≥65 years) perspectives on patient involvement in TEP in the acute setting. Methods Systematic database search was performed in MEDLINE, EMBASE, PsycInfo and CINAHL databases as well as grey literature from database inception to June 8, 2023, using the Sample (older patients, clinicians, acute setting; studies relating to patients whose main diagnosis was cancer or single organ failure were excluded as these conditions may have specific TEP considerations), Phenomenon of Interest (Treatment Escalation Planning), Design (any including interview, observational, survey), Evaluation (Shared Decision-Making), Research type (qualitative, quantitative, mixed methods) tool. Primary data (published participant quotations, field notes, survey results) and descriptive author comments were extracted and qualitative thematic synthesis was performed to generate analytic themes. Quality assessment was made using the Critical Appraisal Skills Programme and Mixed Methods Appraisal Tools. The GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research) approach was used to assess overall confidence in each thematic finding according to methodology, coherence, adequacy and relevance of the contributing studies. The study protocol was registered on PROSPERO, CRD42022361593. Findings Following duplicate exclusion there were 1916 studies screened and ultimately 13 studies were included, all from European and North American settings. Clinician-orientated themes were: treatment escalation is a medical decision (high confidence); clinicians want the best for their patients amidst uncertainty (high confidence); involving patients and families in decisions is not always meaningful and can involve conflict (high confidence); treatment escalation planning exists within the clinical environment, organisation and society (moderate confidence). Patient-orientated themes were: patients' relationships with Treatment Escalation Planning are complex (low confidence); interactions with doctors are important but communication is not always easy (moderate confidence); patients are highly aware of their families when considering TEP (moderate confidence). Interpretation Based on current evidence, TEP decisions appear dominated by clinicians' perspectives, motivated by achieving the best for patients and challenged by complex decisions, communication and environmental factors; older patients' perspectives have seldom been explored, but their input on decisions may be modest. Presenting the context and challenge of SDM during professional education may allow reflection and a more nuanced approach. Future research should seek to understand what approach to TEP decision-making patients and clinicians consider to be optimum in the acute setting so that a mutually acceptable standard can be defined in policy. Funding HCA International and the NIHR Imperial Biomedical Research Centre.
Collapse
Affiliation(s)
- Bronwen E. Warner
- Division of Anaesthetics, Pain Management and Intensive Care, Department of Surgery and Cancer, Imperial College London, UK
| | - Adam Lound
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, UK
| | - Kate Grailey
- Centre for Health Policy, Institute for Global Health Innovation, Department of Surgery and Cancer, Imperial College London, UK
| | | | - Mary Wells
- Department of Surgery and Cancer, Imperial College London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Stephen J. Brett
- Division of Anaesthetics, Pain Management and Intensive Care, Department of Surgery and Cancer, Imperial College London, UK
- Department of Intensive Care Medicine, Imperial College Healthcare NHS Trust London, London, UK
| |
Collapse
|
5
|
Hartanto M, Moore G, Robbins T, Suthantirakumar R, Slowther AM. The experiences of adult patients, families, and healthcare professionals of CPR decision-making conversations in the United Kingdom: A qualitative systematic review. Resusc Plus 2023; 13:100351. [PMID: 36686325 DOI: 10.1016/j.resplu.2022.100351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 01/08/2023] Open
Abstract
Aim To conduct a qualitative systematic review on the experiences of patients, families, and healthcare professionals (HCPs) of CPR decision-making conversations in the United Kingdom (UK). Methods The databases PubMed, Embase, Emcare, CINAHL, and PsycInfo were searched. Studies published from 1 January 2012 describing experiences of CPR decision-making conversations in the UK were included. Included studies were critically appraised using the CASP tool. Thematic synthesis was conducted. Results From 684 papers identified, ten studies were included. Four key themes were identified:(i) Initiation of conversations - Key prompts for the discussion included clinical deterioration and poor prognosis. There are different perspectives about who should initiate conversations.(ii) Involvement of patients and families - HCPs were reluctant to involve patients who they thought would become distressed by the conversation, while patients varied in their desire to be involved. Patients wanted family support while HCPs viewed families as potential sources of conflict.(iii) Influences on the content of conversations - Location, context, HCPs' attitudes and emotions, and uncertainty of prognosis influenced the content of conversations.(iv) Conversation outcomes - Range of outcomes included emotional distress, sense of relief and value, disagreements, and incomplete conversations. Conclusions There is inconsistency in how these conversations occur, patients' desire to be involved, and between patients' and HCPs' views on the role of families in these conversations. CPR discussions raise ethical challenges for HCPs. HCPs need training and pastoral support in conducting CPR discussions. Patients and families need education on CPR recommendations and support after discussions.
Collapse
|
6
|
Kesten JM, Redwood S, Pullyblank A, Tavare A, Pocock L, Brant H, Hill EM, Tutaev M, Shum RZ, Banks J. Using the recommended summary plan for emergency care and treatment (ReSPECT) in care homes: a qualitative interview study. Age Ageing 2022; 51:6770071. [PMID: 36273344 PMCID: PMC9588387 DOI: 10.1093/ageing/afac226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is an advance care planning process designed to facilitate discussion and documentation of preferences for care in a medical emergency. Advance care planning is important in residential and nursing homes. AIM To explore the views and experiences of GPs and care home staff of the role of ReSPECT in: (i) supporting, and documenting, conversations about care home residents' preferences for emergency care situations, and (ii) supporting decision-making in clinical emergencies. SETTING/PARTICIPANTS Sixteen GPs providing clinical care for care home residents and 11 care home staff in the West of England. METHODS A qualitative research design using semi-structured interviews. RESULTS Participants' accounts described the ReSPECT process as facilitating person-centred conversations about residents' preferences for care in emergency situations. The creation of personalised scenarios supported residents to consider their preferences. However, using ReSPECT was complex, requiring interactional work to identify and incorporate resident or relative preferences. Subsequent translation of preferences into action during emergency situations also proved difficult in some cases. Care staff played an important role in facilitating and supporting ReSPECT conversations and in translating it into action. CONCLUSIONS The ReSPECT process in care homes was positive for GPs and care home staff. We highlight challenges with the process, communication of preferences in emergency situations and the importance of balancing detail with clarity. This study highlights the potential for a multi-disciplinary approach engaging care staff more in the process.
Collapse
Affiliation(s)
- Joanna May Kesten
- Address correspondence to: Joanna May Kesten, NIHR ARC West at University Hospitals Bristol and Weston NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol BS1 2NT, UK.
| | - Sabi Redwood
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
| | - Anne Pullyblank
- West of England Academic Health Science Network (West of England AHSN), Bristol, UK,North Bristol NHS Trust, Bristol, UK
| | - Alison Tavare
- West of England Academic Health Science Network (West of England AHSN), Bristol, UK
| | - Lucy Pocock
- Population Health Sciences, Bristol Medical School, University of Bristol
| | - Heather Brant
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
| | - Elizabeth M Hill
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
| | | | - Rui Zhi Shum
- Population Health Sciences, Bristol Medical School, University of Bristol
| | - Jon Banks
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
| |
Collapse
|
7
|
McDermott A, Woodall CA, Chamberlain C, Selman L, Pocock LV. Which patients received a ReSPECT form, what was documented and what were the patient outcomes? A protocol for a retrospective observational study investigating the impact of the COVID-19 pandemic on the implementation of the ReSPECT process. BMJ Open 2022; 12:e060253. [PMID: 35820746 PMCID: PMC9277023 DOI: 10.1136/bmjopen-2021-060253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is a UK advance care planning (ACP) initiative aiming to standardise the process of creating personalised recommendations for a person's clinical care in a future emergency and therefore improve person-focused care. Implementation of the ReSPECT process across a large geographical area, involving both community and secondary care, has not previously been studied. In particular, it not known whether such implementation is associated with any change in outcomes for those patients with a ReSPECT form.Implementation of ReSPECT in the Bristol, North Somerset and South Gloucestershire (BNSSG) Clinical Commissioning Group (CCG) area overlapped with the first UK COVID-19 wave. It is unclear what impact the pandemic had on the implementation of ReSPECT and if this affected the type of patients who underwent the ReSPECT process, such as those with specific diagnoses or living in care homes. Patterns of clinical recommendations documented on ReSPECT forms during the first year of its implementation may also have changed, particularly with reference to the pandemic.To determine the equity and potential benefits of implementation of the ReSPECT form process in BNSSG and contribute to the ACP evidence base, this study will describe the characteristics of patients in the BNSSG area who had a completed ReSPECT form recorded in their primary care medical records before, during and after the first wave of the COVID-19 pandemic; describe the content of ReSPECT forms; and analyse outcomes for those patients who died with a ReSPECT form. METHODS AND ANALYSIS We will perform an observational retrospective study on data, collected from October 2019 for 12 months. Data will be exported from the CCG Public Health Management data resource, a pseudonymised database linking data from organisations providing health and social care to people across BNSSG. Descriptive statistics of sociodemographic and health-related variables for those who completed the ReSPECT process with a clinician and had a documented ReSPECT form in their notes, in addition to their ReSPECT form responses, will be compared between before, during and after first COVID-19 wave groups. Additionally, routinely collected outcomes for patients who died in our study period will be compared between those who completed the ReSPECT process with a community clinician, hospital clinician or not at all. These include emergency department attendances, emergency hospital admissions, community nurse home visits, hospice referrals, anticipatory medication prescribing, place of death and if the patient died in preferred place of death. ETHICS AND DISSEMINATION Approval has been obtained from a National Health Service Research Ethics Committee (20/YH/0185). Findings will be disseminated to policy decision-makers, care providers and the public through scientific meetings and peer-reviewed publication.
Collapse
Affiliation(s)
- Adam McDermott
- Palliative and End of Life Care Research Group/Centre for Academic Primary Care, Bristol Medical School, Bristol, UK
| | - Claire A Woodall
- Centre for Academic Primary Care, Bristol Medical School, Bristol, UK
| | - Charlotte Chamberlain
- Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Lucy Selman
- Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Lucy Victoria Pocock
- Palliative and End of Life Care Research Group/Centre for Academic Primary Care, Bristol Medical School, Bristol, UK
| |
Collapse
|
8
|
Hawkes CA, Griffin J, Eli K, Griffiths F, Slowther AM, Fritz Z, Underwood M, Baldock C, Gould D, Lilford R, Jacques C, Warwick J, Perkins GD. Implementation of ReSPECT in acute hospitals: A retrospective observational study. Resuscitation 2022; 178:26-35. [PMID: 35779800 DOI: 10.1016/j.resuscitation.2022.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/09/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022]
Abstract
AIMS To evaluate, in UK acute hospitals, the early implementation of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT), which embeds cardiopulmonary resuscitation (CPR) recommendations within wider emergency treatment plans. To understand for whom and how the process was being used and the quality of form completion. METHODS A retrospective observational study evaluating emergency care and treatment planning approaches used in acute UK hospitals (2015-2019), and in six English hospital trusts the extent of ReSPECT use, patient characteristics and completion quality in a sample 3000 patient case notes. RESULTS The use of stand-alone Do Not Attempt Cardiopulmonary Resuscitation forms fell from 133/186 hospitals in 2015 to 64/186 in 2019 (a 38% absolute reduction). ReSPECT accounted for 52% (36/69) of changes. In the six sites, ReSPECT was used for approximately 20% of patients (range 6%-41%). They tended to be older, to have had an emergency medical admission, to have cognitive impairment and a lower predicted 10 year survival. Most (653/706 (92%)) included a 'not for attempted resuscitation' recommendation 551/706 (78%) had at least one other treatment recommendation. Capacity was not recorded on 13% (95/706) of forms; 11% (79/706) did not record patient/family involvement. CONCLUSIONS ReSPECT use accounts for 52% of the change, observed between 2015 and 2019, from using standalone DNACPR forms to approaches embedding DNACPR decisions within in wider emergency care plans in NHS hospitals in the UK. Whilst recommendations include other emergencies most still tend to focus on recommendations relating to CPR. Completion of ReSPECT forms requires improvement. STUDY REGISTRATION https://www.isrctn.com/ISRCTN11112933.
Collapse
|
9
|
Eli K, Huxley CJ, Hawkes CA, Perkins GD, Slowther AM, Griffiths F. Why are some ReSPECT conversations left incomplete? A qualitative case study analysis. Resusc Plus 2022; 10:100255. [PMID: 35734306 PMCID: PMC9207560 DOI: 10.1016/j.resplu.2022.100255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/10/2022] [Accepted: 05/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background As an emergency care and treatment planning process (ECTP), a key feature of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is the engagement of patients and/or their representatives in conversations about treatment options including, but not limited to, cardiopulmonary resuscitation (CPR). However, qualitative research suggests that some ReSPECT conversations lead to partial or no decision-making about treatment recommendations. This paper explores why some ReSPECT conversations are left incomplete. Methods Drawing on observation and interview data collected in four National Health Service (NHS) hospital sites in England, this paper offers an in-depth exploration of six case studies in which ReSPECT conversations were incomplete. Using thematic analysis, we triangulate fieldnote data documenting these conversations with interview data in which the doctors who conducted these conversations shared their perceptions and reflected on their decision-making processes. Results We identified two themes, both focused on ‘mismatch’: (1) Mismatch between the doctor’s clinical priorities and the patient’s/family’s immediate needs; and (2) mismatch between the doctor’s conversation scripts, which included patient autonomy, the feasibility of CPR, and what medicine can and should do to prolong a patient’s life, and the patient’s/family’s understandings of these concepts. Conclusions This case study analysis of six ReSPECT conversations found that mismatch between doctors’ priorities and understandings and those of patients and/or their relatives led to incomplete ReSPECT conversations. Future research should explore methods to overcome these mismatches.
Collapse
Affiliation(s)
- Karin Eli
- Warwick Medical School, University of Warwick, UK
- Corresponding authors at: Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry CV4 7AL, UK.
| | | | | | - Gavin D. Perkins
- Warwick Medical School, University of Warwick, UK
- University Hospitals Birmingham NHS Foundation Trust, UK
| | | | - Frances Griffiths
- Warwick Medical School, University of Warwick, UK
- Corresponding authors at: Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry CV4 7AL, UK.
| |
Collapse
|
10
|
Bird J, Wilson F. Do not resuscitate orders in the time of COVID-19: Exploring media representations and implications for public and professional understandings. Progress in Palliative Care 2022. [DOI: 10.1080/09699260.2022.2052505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Joanne Bird
- Department of Oncology & Metabolism, University of Sheffield, Sheffield, UK
| | - Fiona Wilson
- Health Sciences School, University of Sheffield, Sheffield, UK
| |
Collapse
|
11
|
Eli K, Hawkes C, Perkins GD, Slowther AM, Griffiths F. Caring in the silences: why physicians and surgeons do not discuss emergency care and treatment planning with their patients - an analysis of hospital-based ethnographic case studies in England. BMJ Open 2022; 12:e046189. [PMID: 35256437 PMCID: PMC8905976 DOI: 10.1136/bmjopen-2020-046189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Despite increasing emphasis on integrating emergency care and treatment planning (ECTP) into routine medical practice, clinicians continue to delay or avoid ECTP conversations with patients. However, little is known about the clinical logics underlying barriers to ECTP conversations. OBJECTIVE This study aims to develop an ethnographic account of how and why clinicians defer and avoid ECTP conversations, and how they rationalise these decisions as they happen. DESIGN A multisited ethnographic study. SETTING Medical, orthopaedic and surgical wards in hospitals within four acute National Health Service trusts in England. PARTICIPANTS Thirty-four doctors were formally observed and 32 formally interviewed. Following an ethnographic case study approach, six cases were selected for in-depth analysis. ANALYSIS Fieldnote data were triangulated with interview data, to develop a 'thick description' of each case. Using a conceptual framework of care, the analysis highlighted the clinical logics underlying these cases. RESULTS The deferral or avoidance of ECTP conversations was driven by concerns over caring well, with clinicians attempting to optimise both medical and bedside practice. Conducting an ECTP conversation carefully meant attending to patients' and relatives' emotions and committing sufficient time for an in-depth discussion. However, conversation plans were often disrupted by issues related to timing and time constraints, leading doctors to defer these conversations, sometimes indefinitely. Additionally, whereas surgeons and geriatricians deferred conversations because they did not have the time to offer detailed discussions, emergency and acute medicine clinicians deferred conversations because the high-turnover ward environment, combined with patients' acute conditions, meant triaging conversations to those most in need. CONCLUSION Overcoming barriers to ECTP conversations is not simply a matter of enhancing training or hospital policies, but of promoting good conversational practices that take into account the affordances of hospital time and space, as well as clinicians' understandings of caring well.
Collapse
Affiliation(s)
- Karin Eli
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Claire Hawkes
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | |
Collapse
|
12
|
Huxley CJ, Eli K, Hawkes CA, Perkins GD, George R, Griffiths F, Slowther AM. General practitioners' experiences of emergency care and treatment planning in England: a focus group study. BMC Fam Pract 2021; 22:128. [PMID: 34167478 PMCID: PMC8224258 DOI: 10.1186/s12875-021-01486-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 06/07/2021] [Indexed: 11/21/2022]
Abstract
Background Emergency Care and Treatment Plans are recommended for all primary care patients in the United Kingdom who are expected to experience deterioration of their health. The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) was developed to integrate resuscitation decisions with discussions about wider goals of care. It summarises treatment recommendations discussed and agreed between patients and their clinicians for a future emergency situation and was designed to meet the needs of different care settings. Our aim is to explore GPs’ experiences of using ReSPECT and how it transfers across the primary care and secondary care interface. Methods We conducted five focus groups with GPs in areas being served by hospitals in England that have implemented ReSPECT. Participants were asked about their experience of ReSPECT, how they initiate ReSPECT-type conversations, and their experiences of ReSPECT-type recommendations being communicated across primary and secondary care. Focus groups were transcribed and analysed using Thematic Analysis. Results GPs conceptualise ReSPECT as an end of life planning document, which is best completed in primary care. As an end of life care document, completing ReSPECT is an emotional process and conversations are shaped by what a ‘good death’ is thought to be. ReSPECT recommendations are not always communicated or transferable across care settings. A focus on the patient’s preferences around death, and GPs’ lack of specialist knowledge, could be a barrier to completion of ReSPECT that is transferable to acute settings. Conclusion Conceptualising ReSPECT as an end of life care document suggests a difference in how general practitioners understand ReSPECT from its designers. This impacts on the transferability of ReSPECT recommendations to the hospital setting. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01486-w.
Collapse
Affiliation(s)
- Caroline J Huxley
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
| | - Karin Eli
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
| | - Claire A Hawkes
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
| | - Rob George
- St Christopher's Hospice, 51-59 Lawrie Park Road, London, SE26 6DZ, UK
| | - Frances Griffiths
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK.
| | - Anne-Marie Slowther
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
| |
Collapse
|
13
|
Poveda-Moral S, de la Casa PJM, Sánchez-Valero P, Pomares-Quintana N, Vicente-García M, Falcó-Pegueroles A. Association between knowledge and attitudes towards advance directives in emergency services. BMC Med Ethics 2021; 22:75. [PMID: 34158034 PMCID: PMC8218476 DOI: 10.1186/s12910-021-00646-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 06/09/2021] [Indexed: 12/02/2022] Open
Abstract
Background Implementing the routine consultation of patient advance directives in hospital emergency departments and emergency medical services has become essential, given that advance directives constitute the frame of reference for care personalisation and respect for patients’ values and preferences related to healthcare. The aim of this study was to assess the levels and relationship of knowledge and attitudes of nursing and medical professionals towards advance directives in hospital emergency departments and emergency medical services, and to determine the correlated and predictor variables of favourable attitudes towards advance directives. Methods Observational, descriptive, and cross-sectional study. The study was conducted in the emergency department of a second-level hospital and in the emergency medical service. Data collection was performed from January 2019 to February 2020. The STROBE guidelines were followed for the preparation of the study. Results A total of 173 healthcare professionals responded to the questionnaire. Among them, 91.3% considered that they were not sufficiently informed about advance directives, and 74% acknowledged not having incorporated them into their usual practice. Multinomial analysis indicated a statistically significant relationship between the variable emergency medical service and having more favourable attitudes towards consulting the advance directives in their practical application (OR 2.49 [95% CI 1.06–5.88]; p = 0.037) and compliance in complex scenarios (OR 3.65 [95% CI 1.58 − 8.41]; p = 0.002). Working the afternoon and night shift was a predictor variable for obtaining a higher score with respect to attitudes in complex scenarios. Conclusion There is an association between the level of knowledge that nursing and medical professionals have about advance directives and the scores obtained on the attitude scales at the time of practical implementation and in complex scenarios. This shows that the more knowledge professionals have, the more likely they are to consult patients' advance directives and to respect their wishes and preferences for care and/or treatment.
Collapse
Affiliation(s)
- Silvia Poveda-Moral
- School of Nursing, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain. .,Escola Universitària D'Infermeria I Teràpia Ocupacional de Terrassa (EUIT), Universitat Autònoma de Barcelona, Calle de La Riba, 90, 08221, Terrassa, Barcelona, Catalonia, Spain.
| | | | - Pere Sánchez-Valero
- Coordinador Territorial Servicio de Emergencias Médicas, Generalitat de Catalunya, Barcelona, Catalonia, Spain
| | | | | | - Anna Falcó-Pegueroles
- School of Nursing. Faculty of Medicine and Health Sciences. Consolidated Research Group SGR 269 Quantitative Psychology, University of Barcelona, Barcelona, Spain
| |
Collapse
|
14
|
Eli K, Hawkes CA, Ochieng C, Huxley CJ, Baldock C, Fortune PM, Fuld J, Perkins GD, Slowther AM, Griffiths F. Why, when and how do secondary-care clinicians have emergency care and treatment planning conversations? Qualitative findings from the ReSPECT Evaluation study. Resuscitation 2021; 162:343-50. [PMID: 33482270 DOI: 10.1016/j.resuscitation.2021.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/07/2020] [Accepted: 01/04/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is an emergency care and treatment planning (ECTP) process, developed to offer a patient-centred approach to deciding about and recording treatment recommendations. Conversations between clinicians and patients or their representatives are central to the ReSPECT process. This study aims to understand why, when, and how ReSPECT conversations unfold in practice. METHODS ReSPECT conversations were observed in hospitals within six acute National Health Service (NHS) trusts in England; the clinicians who conducted these conversations were interviewed. Following observation-based thematic analysis, five ReSPECT conversation types were identified: resuscitation and escalation; confirmation of decision; bad news; palliative care; and clinical decision. Interview-based thematic analysis examined the reasons and prompts for each conversation type, and the level of detail and patient engagement in these different conversations. RESULTS Whereas resuscitation and escalation conversations concerned possible futures, palliative care and bad news conversations responded to present-tense changes. Conversations were timed to respond to organisational, clinical, and patient/relative prompts. While bad news and palliative care conversations included detailed discussions of treatment options beyond CPR, this varied in other conversation types. ReSPECT conversations varied in doctors' engagement with patient/relative preferences, with only palliative care conversations consistently including an open-ended approach. CONCLUSIONS While ReSPECT supports holistic, person-centred, anticipatory decision-making in some situations, a gap remains between the ReSPECT's aims and their implementation in practice. Promoting an understanding and valuing of the aims of ReSPECT among clinicians, supported by appropriate training and structural support, will enhance ReSPECT conversations.
Collapse
|
15
|
Svantesson M, Griffiths F, White C, Bassford C, Slowther A. Ethical conflicts during the process of deciding about ICU admission: an empirically driven ethical analysis. J Med Ethics 2021; 47:medethics-2020-106672. [PMID: 33402429 PMCID: PMC8639921 DOI: 10.1136/medethics-2020-106672] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/20/2020] [Accepted: 10/25/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Besides balancing burdens and benefits of intensive care, ethical conflicts in the process of decision-making should also be recognised. This calls for an ethical analysis relevant to clinicians. The aim was to analyse ethically difficult situations in the process of deciding whether a patient is admitted to intensive care unit (ICU). METHODS Analysis using the 'Dilemma method' and 'wide reflective equilibrium', on ethnographic data of 45 patient cases and 96 stakeholder interviews in six UK hospitals. ETHICAL ANALYSIS Four moral questions and associated value conflicts were identified. (1) Who should have the right to decide whether a patient needs to be reviewed? Conflicting perspectives on safety/security. (2) Does the benefit to the patient of getting the decision right justify the cost to the patient of a delay in making the decision? Preventing longer-term suffering and understanding patient's values conflicted with preventing short-term suffering and provision of security. (3) To what extent should the intensivist gain others' input? Professional independence versus a holistic approach to decision-making. (4) Should the intensivist have an ongoing duty of care to patients not admitted to ICU? Short-term versus longer-term duty to protect patient safety. Safety and security (experienced in a holistic sense of physical and emotional security for patients) were key values at stake in the ethical conflicts identified. The life-threatening nature of the situation meant that the principle of autonomy was overshadowed by the duty to protect patients from harm. The need to fairly balance obligations to the referred patient and to other patients was also recognised. CONCLUSION Proactive decision-making including advance care planning and escalation of treatment decisions may support the inclusion of patient autonomy. However, our analysis invites binary choices, which may not sufficiently reflect reality. This calls for a complementary relational ethics analysis.
Collapse
Affiliation(s)
- Mia Svantesson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Frances Griffiths
- Warwick Medical School, University of Warwick Warwick Medical School, Coventry, UK
| | - Catherine White
- Patient and Public Representative, Trustee, ICUsteps - the Intensive Care Patient Support Charity, Coventry, UK
| | - Chris Bassford
- Department of Anaesthesia, Critical Care and Pain, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, Coventry, UK
| | - AnneMarie Slowther
- Warwick Medical School, University of Warwick Warwick Medical School, Coventry, UK
| |
Collapse
|