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{
  "resourceType": "Questionnaire",
  "text": {
    "status": "additional",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>What is ReSPECT?</h3><p>ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment. The ReSPECT process creates a summary of personalised recommendations for a person’s clinical care in a future emergency in which they do not have capacity to make or express choices. Such emergencies may include death or cardiac arrest, but are not limited to those events. The process is intended to respect both patient preferences and clinical judgement. The agreed realistic clinical recommendations that are recorded include a recommendation on whether or not CPR should be attempted if the person’s heart and breathing stop.</p></div>"
  },
  "url": "https://fhir.nottinghamshire.gov.uk/STU3/Questionnaire/ReSPECT_Form",
  "version": "0.0.1",
  "name": "ReSPECT Form",
  "title": "ReSPECT Form",
  "status": "draft",
  "date": "2021-02-25T12:00:00Z",
  "publisher": "NottsCC",
  "description": "ReSPECT Form - Recommended Summary Plan for Emergency Care and Treatment",
  "purpose": "ReSPECT Form - Recommended Summary Plan for Emergency Care and Treatment",
  "subjectType": [
    "Patient"
  ],
  "item": [
    {
      "linkId": "1",
      "text": "Patient Details and Date Completed will be shared via 'QuestionnaireResponse.subject' and 'QuestionnaireResponse.authored' respectively",
      "type": "display"
    },
    {
      "linkId": "2",
      "text": "Shared understanding of my health and current condition",
      "type": "group",
      "required": false,
      "item": [
        {
          "linkId": "2.1",
          "text": "Summary of relevant information for this plan including diagnoses and relevant personal circumstances:",
          "type": "text",
          "required": false
        },
        {
          "linkId": "2.2",
          "text": "Details of other relevant care planning documents and where to find them (e.g. Advance or Anticipatory Care Plan; Advanced Decision to Refuse Treatment or Advanced Directive; Emergency Plan for Carer):",
          "type": "text",
          "required": false
        },
        {
          "linkId": "2.3",
          "text": "I have a legal welfare proxy in place (e.g. registered welfare attorney, person with parental responsibilities) - if yes provide details in Section 8",
          "type": "choice",
          "required": false,
          "option": [
            {
              "valueCoding": {
                "code": "yes",
                "display": "Yes"
              }
            },
            {
              "valueCoding": {
                "code": "no",
                "display": "No"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "3",
      "text": "What matters to me in decisions about my treatment and care in an emergency",
      "type": "group",
      "required": false,
      "item": [
        {
          "linkId": "3.1",
          "text": "Mark on scale of 0-10, where 0 = 'Living as long as possible matters to me most' and 10 = 'Quality of life and comfort matters to me most':",
          "type": "choice",
          "required": false,
          "option": [
            {
              "valueCoding": {
                "code": "0",
                "display": "0 - Living as long as possible matters to me most"
              }
            },
            {
              "valueCoding": {
                "code": "1",
                "display": "1"
              }
            },
            {
              "valueCoding": {
                "code": "2",
                "display": "2"
              }
            },
            {
              "valueCoding": {
                "code": "3",
                "display": "3"
              }
            },
            {
              "valueCoding": {
                "code": "4",
                "display": "4"
              }
            },
            {
              "valueCoding": {
                "code": "5",
                "display": "5"
              }
            },
            {
              "valueCoding": {
                "code": "6",
                "display": "6"
              }
            },
            {
              "valueCoding": {
                "code": "7",
                "display": "7"
              }
            },
            {
              "valueCoding": {
                "code": "8",
                "display": "8"
              }
            },
            {
              "valueCoding": {
                "code": "9",
                "display": "9"
              }
            },
            {
              "valueCoding": {
                "code": "10",
                "display": "10 - Quality of life and comfort matters to me most"
              }
            }
          ]
        },
        {
          "linkId": "3.2",
          "text": "What I most value:",
          "type": "text",
          "required": false
        },
        {
          "linkId": "3.3",
          "text": "What I most fear / wish to avoid:",
          "type": "text",
          "required": false
        }
      ]
    },
    {
      "linkId": "4",
      "text": "Clinical recommendations for emergency care and treatment",
      "type": "group",
      "required": false,
      "item": [
        {
          "linkId": "4.1",
          "text": "Clinical recommendation:",
          "type": "choice",
          "required": true,
          "option": [
            {
              "valueCoding": {
                "code": "life",
                "display": "Prioritise extending life"
              }
            },
            {
              "valueCoding": {
                "code": "balance",
                "display": "Balance extending life with comfort and valued outcomes"
              }
            },
            {
              "valueCoding": {
                "code": "comfort",
                "display": "Prioritise comfort"
              }
            }
          ]
        },
        {
          "linkId": "4.2",
          "text": "Now provide clinical guidance on specific realistic interventions that may or may not be wanted or clinically appropriate (including being taken or admitted to hospital +/- receiving life support) and your reasoning for this guidance",
          "type": "text",
          "required": false
        },
        {
          "linkId": "4.3",
          "text": "CPR:",
          "type": "choice",
          "required": false,
          "option": [
            {
              "valueCoding": {
                "code": "cpr-recommended",
                "display": "CPR attempts recommended (Adult or Child)"
              }
            },
            {
              "valueCoding": {
                "code": "modified-cpr",
                "display": "For modified CPR (CHILD ONLY, AS DETAILED ABOVE)"
              }
            },
            {
              "valueCoding": {
                "code": "cpr-not-recommended",
                "display": "CPR attempts NOT recommended (Adult or Child)"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "5",
      "text": "Capacity for involvement in making this plan",
      "type": "group",
      "required": false,
      "item": [
        {
          "linkId": "5.1",
          "text": "Does the person have capacity to participate in making recommendations on this plan? Document the full capacity assessment in the clinical record.",
          "type": "choice",
          "required": true,
          "option": [
            {
              "valueCoding": {
                "code": "yes",
                "display": "Yes"
              }
            },
            {
              "valueCoding": {
                "code": "no",
                "display": "No"
              }
            }
          ]
        },
        {
          "linkId": "5.2",
          "text": "If no, in what way does this person lack capacity?  If the person lacks capacity a ReSPECT conversation must take place with the family and/or legal welfare proxy.",
          "type": "text",
          "enableWhen": [
            {
              "question": "5.1",
              "answerCoding": {
                "code": "no"
              }
            }
          ],
          "required": true
        }
      ]
    },
    {
      "linkId": "6",
      "text": "Involvement in making this plan",
      "type": "group",
      "required": false,
      "item": [
        {
          "linkId": "6.1",
          "text": "The clinician(s) signing this plan is/are confirming that (select A,B or C, OR complete section D below):",
          "type": "choice",
          "required": true,
          "option": [
            {
              "valueCoding": {
                "code": "A",
                "display": "A: This person has mental capacity to participate in making these recommendations. They have been fully involved in this plan"
              }
            },
            {
              "valueCoding": {
                "code": "B",
                "display": "B: This person does not have the mental capacity, even with support, to participate in making these recommendations.  Their past and present views, where ascertainable, have been taken into account. The plan has been made, where applicable, in consultation with their legal proxy, or where no proxy, with family members/friends"
              }
            },
            {
              "valueCoding": {
                "code": "C",
                "display": "C: This person is less than 18 years old (16 in Scotland) and (please select 1 or 2, and also 3 as applicable or explain in section D below)"
              }
            },
            {
              "valueCoding": {
                "code": "D",
                "display": "D: If no other option has been selected, valid reasons must be stated here: (Document full explanation in the clinical record.)"
              }
            }
          ]
        },
        {
          "linkId": "6.2",
          "text": "Please select 1 or 2.",
          "type": "choice",
          "enableWhen": [
            {
              "question": "6.1",
              "answerCoding": {
                "code": "C"
              }
            }
          ],
          "required": true,
          "option": [
            {
              "valueCoding": {
                "code": "1",
                "display": "1: They have sufficient maturity and understanding to participate in making this plan"
              }
            },
            {
              "valueCoding": {
                "code": "2",
                "display": "2: They do not have sufficient maturity and understanding to participate in this plan. Their views, when known, have been taken into account."
              }
            }
          ]
        },
        {
          "linkId": "6.3",
          "text": "3: Those holding parental responsibility have been fully involved in discussing and making this plan.",
          "type": "boolean",
          "enableWhen": [
            {
              "question": "6.1",
              "answerCoding": {
                "code": "C"
              }
            }
          ],
          "required": false
        },
        {
          "linkId": "6.4",
          "text": "D: Specify reasons",
          "type": "text",
          "enableWhen": [
            {
              "question": "6.1",
              "answerCoding": {
                "code": "C"
              }
            },
            {
              "question": "6.1",
              "answerCoding": {
                "code": "D"
              }
            }
          ],
          "required": false
        }
      ]
    },
    {
      "linkId": "7",
      "text": "Clinicians' signatures",
      "type": "group",
      "required": false,
      "item": [
        {
          "linkId": "7.1",
          "text": "Senior responsible clinician",
          "type": "group",
          "required": false,
          "item": [
            {
              "linkId": "7.1.1",
              "text": "Grade/speciality",
              "type": "string",
              "required": false
            },
            {
              "linkId": "7.1.2",
              "text": "Clinician name",
              "type": "string",
              "required": false
            },
            {
              "linkId": "7.1.3",
              "text": "GMC/NMC/HCPC no.",
              "type": "string",
              "required": false
            },
            {
              "linkId": "7.1.4",
              "text": "Signature",
              "type": "string",
              "required": false
            },
            {
              "linkId": "7.1.5",
              "text": "Date and time",
              "type": "dateTime",
              "required": false
            }
          ]
        },
        {
          "linkId": "7.2",
          "text": "Other clinicians",
          "type": "group",
          "required": false,
          "repeats": true,
          "item": [
            {
              "linkId": "7.2.1",
              "text": "Grade/speciality",
              "type": "string",
              "required": false
            },
            {
              "linkId": "7.2.2",
              "text": "Clinician name",
              "type": "string",
              "required": false
            },
            {
              "linkId": "7.2.3",
              "text": "GMC/NMC/HCPC no.",
              "type": "string",
              "required": false
            },
            {
              "linkId": "7.2.4",
              "text": "Signature",
              "type": "string",
              "required": false
            },
            {
              "linkId": "7.2.5",
              "text": "Date and time",
              "type": "dateTime",
              "required": false
            }
          ]
        }
      ]
    },
    {
      "linkId": "8",
      "text": "Emergency contacts and those involved in discussing this plan",
      "type": "group",
      "required": false,
      "item": [
        {
          "linkId": "8.1",
          "text": "Primary emergency contact",
          "type": "group",
          "required": false,
          "item": [
            {
              "linkId": "8.1.1",
              "text": "Name",
              "type": "string",
              "required": false
            },
            {
              "linkId": "8.1.2",
              "text": "Involved in planning",
              "type": "boolean",
              "required": false
            },
            {
              "linkId": "8.1.3",
              "text": "Emergency contact no.",
              "type": "string",
              "required": false
            },
            {
              "linkId": "8.1.4",
              "text": "Signature",
              "type": "string",
              "required": false
            }
          ]
        },
        {
          "linkId": "8.2",
          "text": "Other emergency contacts",
          "type": "group",
          "required": false,
          "repeats": true,
          "item": [
            {
              "linkId": "8.2.1",
              "text": "Name",
              "type": "string",
              "required": false
            },
            {
              "linkId": "8.2.2",
              "text": "Involved in planning",
              "type": "boolean",
              "required": false
            },
            {
              "linkId": "8.2.3",
              "text": "Emergency contact no.",
              "type": "string",
              "required": false
            },
            {
              "linkId": "8.2.4",
              "text": "Signature",
              "type": "string",
              "required": false
            }
          ]
        }
      ]
    },
    {
      "linkId": "9",
      "text": "Form reviewed (e.g. for change of care setting) and remains relevant",
      "type": "group",
      "required": false,
      "item": [
        {
          "linkId": "9.1",
          "text": "Review details",
          "type": "group",
          "required": false,
          "repeats": true,
          "item": [
            {
              "linkId": "9.1.1",
              "text": "Review date",
              "type": "date",
              "required": false
            },
            {
              "linkId": "9.1.2",
              "text": "Grade/speciality",
              "type": "string",
              "required": false
            },
            {
              "linkId": "9.1.3",
              "text": "Clinician name",
              "type": "string",
              "required": false
            },
            {
              "linkId": "9.1.4",
              "text": "GMC/NMC/HCPC no.",
              "type": "string",
              "required": false
            },
            {
              "linkId": "9.1.5",
              "text": "Signature",
              "type": "string",
              "required": false
            }
          ]
        }
      ]
    }
  ]
}

name : ReSPECT Form

{

}