General Practitioners’ Experiences of Emergency Care and Treatment Planning in England: A Focus Group Study

Abstract

BackgroundEmergency 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.MethodsWe conducted five focus groups with GPs in areas being served by hospitals in England that have implemented ReSPECT. GPs 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. ResultsGPs 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. ConclusionConceptualising 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.

Why are some ReSPECT conversations left incomplete? A qualitative case study analysis

“…Similarly, we have previously reported that GPs view ReSPECT conversations as ongoing and processual. 19 However, excepting one doctor who encouraged the patient to take her time, the participating doctors aimed at completing the decision-making process in one conversation, timing conversations according to clinical urgency. In our earlier work on the full range of ReSPECT conversations – from those planned but not conducted, to those carried out to completion – we described how time constraints, coupled with clinical prompts such as a patient’s projected deterioration, influence doctors’ decisions about which ReSPECT conversations to prioritise and which to forgo.…”

“…, 17. , 19. In this analysis they employed a new focus – understanding incomplete conversations – and were alert to new themes.…”