Abstract
Background Hospital based Quality Improvement Project focusing on adapting language used on Recommended Summary Plan for Emergency Treatment and Care (ReSPECT) forms to improve patient understanding. Introduction ReSPECT forms have been used to document patient wishes and appropriate escalation of treatment in our hospital since 2019. There continues to be a lack of understanding of phrases used amongst both patients and healthcare professionals; the hospital receives regular complaints. This project explored patients’ perceptions of language used and their thoughts on the ReSPECT discussion, to better guide discussions and documentation. Methods A questionnaire collecting qualitative and quantitative data was performed with 24 patients aged between 59-95 years old with ReSPECT forms on a medical ward (Geriatrics/Endocrine). Results The phrases ‘DNACPR’ and ‘Not for ITU’ were understood by 5/24 patients (21%), ‘Ward based ceiling of care’ was understood by only 1/24 (4%) and ‘prioritising comfort care’ understood by 8/24 patients (34%). Only 6/24 (25%) of patients said they were a ‘little upset’ by their admission conversation about ReSPECT and no patients surveyed were ‘very upset’. Conclusions This first QI cycle found that overall, most patients did not understand the language commonly used on ReSPECT forms, particularly ‘ward-based ceiling of care’. The majority were not upset by the ReSPECT conversation, so a fear of upsetting the patient should not be a barrier to having a clear discussion. The next step in our QI work will be to explore phrases that are better understood by patients and then feedback findings so that we can develop a digital ReSPECT form with drop down options for phrases better understood by patients to describe ceilings of care.
Comments
Thank you, excellent and important work.
We haven't been using information leaflets as in the past we have struggled to maintain this practice. We are going to trial a plastic folder (like those used in maternity for maternity notes) to put people's discharge documentation and their ReSPECT forms in. This will have jargon busting information about what a ReSPECT form is and what the terms 'DNACPR' etc mean.
We have also trialled patients understanding of GP-suggested phrases for drop down options on a new digital ReSPECT form (there is also space for free text) with 8 patients:
'To be kept comfortable at home prioritising symptom control - does not want life prolonging treatments' - 5/8 understood this well
'For care at home and any discomfort/distress to be treated effectively - not for hospital admission but for active treatments in the community eg. oral antibiotics' - 5/8 understood this well
'Wishes to avoid hospital admission if possible but consider admission for urgent treatment for reversible conditions if medically indicated' - 8/8 understood this well
'For admission to hospital for appropriate investigation and treatment for any serious health problems. For consideration of intensive care treatment and ventilation if medically appropriate' - 8/8 understood this well.
These phrases are now in our Bristol / S Glos / N Somerset digital forms, being used in primary care and hopefully soon in secondary care. We have an additional section for hospital level treatment escalation decisions.
Thank you- interested to see how this next iteration will work out. I'm glad there's a separate section for hospital treatment decisions- I recall when ReSPECT was introduced in Southmead when I worked there, and was occasionally criticised for being too vague when it came to requiring specific decisions such as NIV to be made.
Yes! I’m getting better at the community focus but ruining hospital audit results by not referencing NIV. Thank you for your comments!