{"id":1212,"date":"2017-03-17T09:48:16","date_gmt":"2017-03-17T09:48:16","guid":{"rendered":"https:\/\/blogs.bmj.com\/spcare\/?p=1212"},"modified":"2017-03-17T09:48:16","modified_gmt":"2017-03-17T09:48:16","slug":"the-new-respect-form-aretha-franklin-and-our-odd-relationship-with-forms","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/spcare\/2017\/03\/17\/the-new-respect-form-aretha-franklin-and-our-odd-relationship-with-forms\/","title":{"rendered":"The new Respect form- Aretha Franklin and our odd relationship with forms"},"content":{"rendered":"

\"EAB2B298-BCFB-4937-967D-0C60CBDB51C5a\"<\/a>Dr Ollie Minton, Consultant in Palliative Medicine<\/em><\/p>\n

Maybe I should not listen to BBC Radio 4 as much as I do, although it is always stimulating and often leads to debate. This is especially true of the Today program where the \u201cvexed issue\u201d of DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) was recently discussed. However the twist on the usual discussions is the introduction of a new form to allow people to have discussions about all aspects of their treatment. I have not been involved in the process but a large number of organisations have, and it\u2019s been named the respect process<\/a>. \u00a0I like the term process at the very least \u2013 it is not a one off event and implies complexity if nothing else. However, like all things paper or even IT based, the form completion is only really one aspect.<\/p>\n

 <\/p>\n

\u201cI ain’t gonna do you wrong, while you’re gone
\nAin’t gonna do you wrong (ooh) ’cause I don’t want to (ooh)
\nAll I’m askin’ (ooh)<\/em>\u00a0”<\/p>\n

 <\/p>\n

Sorry, got a bit distracted there… All the fault of my esteemed colleague Dr Mark Taubert, who likes to draw parallels to life\u2019s current news and Zeitgeist events, for example David Bowie\u2019s death, or a recent story about a failing satellite<\/a>. \u00a0So I am going to use Aretha Franklin\u2019s anthem to discuss RESPECT<\/a>.\u00a0This is not a column about relationships per se, but about the new proposals from the resuscitation council and others.<\/p>\n

 <\/p>\n

The very sound aim is to move away from placing Do Not Resuscitate decisions in a special category and to more seamlessly incorporate them into routine practice and discussions, especially within the context of myriad other treatments, other than just the one procedure, CPR. The case for doing this has been made by many, including a recent BMJ column<\/a> by Professor David Oliver.\u00a0 I also would draw your attention to Mark Taubert\u2019s excellent work in Wales around how to talk about CPR and DNACPR, especially towards the end of your life. Just google \u201cTalk CPR\u201d, or the website with patient co-directed videos can be found here<\/a>. The videos aimed at educating professionals about the issue, featuring an affected patient and carer in them: https:\/\/www.youtube.com\/watch?v=ImrfD4RbMDE<\/a><\/p>\n

 <\/p>\n

\u201cOoh, your kisses (ooh)
\nSweeter than honey (ooh)
\nAnd guess what (ooh)
\nSo is my money (ooh)
\nAll I want you to do (ooh) for me
\nIs give it to me when you get home (re, re, re ,re)<\/em>\u201d<\/p>\n

 <\/p>\n

Oops, sorry, I was miles away there, please bear with me.<\/p>\n

The lyrics of Aretha\u2019s respect song are relevant not just for this new acronym<\/a> \u00a0\u2013 \u201cFind out what it means to me… I\u2019ve got to have (just a little bit) of respect<\/em>\u201d. I think we can agree we all want that especially if time and prognosis is limited. However this is not simply a palliative medicine problem \u2013 patients are referred late to services and doctors are poor at prognostication and recognising dying. We need to get behind this as a speciality but as the saying goes \u201cit\u2019s everybody\u2019s business\u201d.<\/p>\n

We cannot as professionals force people to have these conversations. Yet we are constantly being told<\/a> that there are\u201cinappropriate admissions\u201d with extensive use of hospitals for frail elderly or complex patients.<\/p>\n

That is way a public information website and campaign \u00a0like TalkCPR in Wales, with its hahtag campaign on Twitter (#TalkCPR) \u00a0is an important and bold strating point to educate everyone<\/em> about the pros and cons of CPR, in particular in life-limiting and palliative illness.<\/p>\n

 <\/p>\n

Alongside this and far more important than cost, it is distressing and affects bereavement to be admitted as an emergency unnecessarily if \u201cavoidable\u201d. For example the increase in admissions we have all seen from nursing homes. I am sure hospital episode statistics will bear this out and the proposed new end of life metrics will allow for more nuance and detailed analysis in time.<\/p>\n

 <\/p>\n

This is a complex procedure and instilling the Respect ethos will take time, money and attention to detail. I think the medical research council framework<\/a> \u00a0is a helpful guide as will the proposed Royal College of Physicians quality improvement hub<\/a>. The fact that every relevant learned society and organisation is already involved should allow the right level of discourse to make it happen. When and how this filters through to the \u201cshop floor\u201d is as a best guess over some years. Whether this means trial by media around death lists and pathways it remains to be seen. I sincerely hope not.<\/p>\n

 <\/p>\n

But the Respect form must not merely become a \u2018palliative\u2019 for the distress symptoms of the medics (anxiety about having these conversations when the patient is actually still able to have them, for fear of making them frightened). And we shouldn\u2019t just create a more benign piece of paper, with less hostile, nasty words (like death): this must also not become a \u2018palliative\u2019 or \u2018sedative\u2019 for the agitated media, hungry for yet more sinisterly worded forms, clandestinely used in hospitals, the \u2018next LCP\u2019.<\/p>\n

 <\/p>\n

I fundamentally believe that the form currently in its 67th<\/sup> version is unlikely to alter practice without significant education and training. In fact, I would rather have a really basic form without realms of information, but an extensive supporting training programme, something like a Serious Illness Conversation training project for all healthcare grades and professionals. This sort of ambitious project has already started in Wales<\/a>.<\/p>\n

 <\/p>\n

The form itself should not be the actual training, however well it is or isn\u2019t worded. It should not serve the purpose of assuaging those fearful of another media storm. In a sense, we should really strive for a system where the form does not matter much at all, and merely acts as an information letter from one healthcare professional to another, held by a patient or their loved-ones: \u201cI have had a conversation about this with Mrs X. Her views are that she\u2019d be up for any treatments doctors feel she may need, just not CPR please. Her family were there when we talked it through. Yours sincerely, Dr O M\u201d. The qualitative text you write on a piece of paper usually trumps any tick boxes in terms of meaningfulness.<\/p>\n

 <\/p>\n

Yes, it\u2019s hardly ever about the paperwork, and always about the actual \u2018meat\u2019 of these serious illness conversations. My feelings on this have not changed since August 2016<\/a>.<\/p>\n

 <\/p>\n

\u201cOr you might walk in (respect, just a little bit)
\nAnd find out I’m gone (just a little bit)
\nI got to have (just a little bit)
\nA little respect (just a little bit)\u201d<\/em><\/p>\n

 <\/p>\n

Sorry, was I singing again?<\/p>\n","protected":false},"excerpt":{"rendered":"

Dr Ollie Minton, Consultant in Palliative Medicine Maybe I should not listen to BBC Radio 4 as much as I do, although it is always stimulating and often leads to debate. This is especially true of the Today program where the \u201cvexed issue\u201d of DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) was recently discussed. However the […]<\/p>\n

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