Abstract
Dear Editor,
We read with interest the article ‘Planning for end of life in the past and present: historical, legal and clinical perspectives on ReSPECT’ 1 and appreciated the thoughtful synthesis of the multidisciplinary complexities surrounding ReSPECT and end-of-life planning. We write to affirm the authors' view of ReSPECT as a means to harness medicine in service of society, culture and individuals – and to reflect on the dissonance between its design and everyday implementation.
Unlike traditional DNARs, ReSPECT has the advantage of being valid across all settings, facilitating continuity of care between community and hospital. However, as doctors on the acute medical take and general medical wards, we observe that the ReSPECT process often begins during acute illness, when urgent decisions must guide inpatient care. Initiating these conversations requires emotional maturity, moral courage and time – all scarce amid crisis-driven care.
Practical challenges further complicate ReSPECT’s intended use. Tension exists between making clinical decisions and understanding what matters to the individual. While the form rightly prompts patient involvement, sections on individual priorities are frequently incomplete. It is appropriate that these decisions occur early in the patient journey, but this can conflict with the goal of meaningful, ongoing planning. This reflects systemic pressures – frequent ward changes, staff turnover and complex patient backgrounds – but also many patients’ lack of ongoing relationships with a familiar clinician, limiting opportunities for iterative advance care planning. A decision that belongs to everyone ends up belonging to no one.
Although conceptually robust, in practice, ReSPECT is often reduced to a de facto DNACPR. Realising its potential requires upstream conversations – in primary care, care homes or outpatient settings 2 – and a shift towards treating it as a dynamic, revisable record. Without this, the form risks becoming a checkbox: a document that gives the illusion of shared understanding where none exists.