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Our next speakers are as Karen Morrow and Dr Jack Fairweather. Um So Karen is a program manager for Realistic Medicine in the NHS Lanarkshire and Jack is a consultant Renal and general physician in uh the University Hospital mcglynn's. They have both been fundamental in the introduction of steps in Lanarkshire building and work started as far back as 2016 where I think they had a hospital uh HEP uh equivalent. Um And so they have a length and breadth of experience that they're going to share with us. Um They're gonna give us their lived experience of implementing treatment, escalation plans, their journey, the barriers they encountered and the solutions they find. So, um I shall hand you over to Karen and Jack. Thank you very much Steven. Um So I'll just start off and thank you for the introduction. Um And as you said, Jack and I have been involved in this, but I'm certainly not on our own and we will acknowledge that at the, at the end of our presentation. Um So Jack and I will do a double act for this session, right? Thank you. Thanks Karen. So, yeah, we're gonna spend the next 20 minutes talking about, about our experience in N H S Lanarkshire. And it comes to really to a specific answer to one of those last questions just posed. They're in the chat. So we're gonna talk about about the background to treatment, escalation, planning and N H S Lanarkshire, all the Robin helpless already alluded to some of that. We'll update you on where we are now in our current challenges and talk about really exciting recent work where we've brought tep and respect together. We'll illustrate that finally with the case discussion and then touch on next steps for us in N H S Lanarkshire before we take time for some questions. So um treatment escalation plans in N H S Lanarkshire been around for well, well before my time in in N H S Lanarkshire and it goes as far back as 2016 when Professor Taylor really lead the work with what at the time were introduced as hospital anticipatory care plans and he's been in the cars there for about seven years in Lanarkshire, but through various different iterations and can happily spend much time talking about that. And more recently, we've been using what was then treatment in escalation and limitation plans. And these have now evolved to just been test treatment escalation plans and these are used now in three acute NHS sites across all specialties for all of us, all in patient's across the piece and, and, and they've been up there, been ups and downs, but much of this was followed, really intensive implementation that Robins already described where he really went around the house is speaking to almost every clinician in N H S Lanarkshire about the process, an individual 1 to 1 training kind program really just highlighting the scale of of intervention required for implementation, roll out for treatment escalation plans that's been undertaken in each Islamic show. And as we already seen, we've got really strong evidence demonstrating benefits including evidence undertaken locally. Looking at hospitals where I'm presenting from now showing a significant reduction in harm's and avoidance of non beneficial interventions for patient's with treatment escalation plans in place. As I said, the treatment escalation plan and the document and the process have evolved um in in many different ways. Um As many people discovered and certainly other boards across Scotland encountered treatment escalation plans really came into the road. I think a lot of the time during the COVID pandemic and much of our approach changed during the course of COVID. And certainly we evolved it so that every patient coming into the front door was receiving a treatment escalation plans. And we've been using feedback at each stage two to evolve the plan and the way it's been used including at times plans for every different specialty, including lots of different specific medical interventions and then more recent changing changes, reflecting feedback and and experience that we've had and So, following on from that, obviously, with the introduction of the COVID and non COVID plan, as Jack has said, um we have captured feedback throughout our process is an important aspect of the feedback was if someone was admitted with abdominal pain, but tested positive for COVID, which planned the use the non COVID or the COVID one. Um So that led us into working together to, to develop an advised plan and it was the the revised treatment escalation plan. So it removed that element of limitations. Um And, and that was to be one size to, to fit all. Um We developed an s far an expert to communicate with our workforce. But fundamentally, we then lead that onto a standard operating procedure, but like everything, um there are limits to what people will read at the time. So following in the footsteps of Robin, many years ago, I went round all of the three acute hospitals to engage with every ward um to capture the medical staff, nursing staff and uh a allied health professionals because we recognized in the revamp of, of this revised plan, it was to be a multidisciplinary approach. Um And certainly, yes, there would be the final agreement with it, the consultant and the team involved in the patient's care. However, it was important that there was the recognition for whom is looking after the patient. If there were concerns, then a treatment escalation was the right discussion to have staff awareness was, was fundamental to this. Um an initial audit, just a snapshot that was carried out several months after the revised plan indicated about a 30% uptake of the revised plan. So what could it do to make that better? So, we initiated a further combs message and through our staff brief and through the pulse providing an article um and then a follow up of a formal audit and as already alluded to in the formal audit lined with our mortality, our annual case smoke Mortality review. And it was encouraging to see that 66% of the patient's reviewed did have some form of treatment escalation. And actually, um 63% of them were the revised plan, which was a 30% increase from the previous um snapshot audit. Similarly, um of that there were a few patient's within the case note mortality review um of which was about 16% that did not have a treatment escalation. Um And again, um as as Robin has mentioned where there is a plan and obviously reduces much uncertainty and the difficulty and that was, was trying to decipher much of what was written and repeated within the case notes. Uh Slight, it's just uh take a moment. Mhm. Sorry. Bear with us. But Stephen, are you able to see our slides? They've gone blank with us. Uh No, not at the minute. Um uh um Let me if you try it slide six or screen screen has gone blank. Can you scroll past it? No, it's all blank blank. Um And even going back the ways we were black now here, I wonder if we, if we stop presenting and then just try again, just try uploading your slides one more time and then if you can't, then I will upload your slides. Yeah, we're still getting nothing. Sorry. It's saying our slide deck is, is, is they're ready for presenting but okay. Just give me one moment that has gone. Okay. Right. Sorry folks. Sorry about this. That's a nice. Yeah, okay. Um I will try uploading your slide deck and go with that. Thanks Stephen. And then we can uh we can have a Christmas the moment next slide, please. Yes. Uh So give me your slide tooth like three, same nothing. So you were at slight number six. Uh Yeah, that's right. So this slide here. That's perfect. Yeah. Thank you. Technical error. But um when you shall get there, thanks Steven. So we're just gonna take a moment just to look at the current iteration of our treatment escalation plan and just highlight some of the key aspects that we've found, as I say evolved over about seven years or so. And so the first thing is the, the yellow box criteria at the beginning. So this is why we identify who should, who should be recommended, who should be considered for treatment escalation plan. And, and this is our approach in energy. Islamic. Sure we've moved away from are kind of everyone at the front door. Everyone who's being admitted, we're not taking approach that, that there should be in selected patient's and we give some guidance here, but it's, it's pretty obvious. Uh We're talking about people who we recognized as being at risk of deterioration. After admission, we, we've encompassed the clinical frailty score based on evidence about your survival after cardiac arrest. For instance, we've also highlighted issues about people with life limiting disease. It's really all of the fairly obvious things, but as I say encompasses that group of patient. So I think we all know who we're talking about. But but specifically, we're not talking about using treatment escalation plans for every single patient admitted. The next session of the form looks about engagement with the decision making process and capacity for making decisions. And that obviously fits with the legal necessities about these kind of decisions. And then the key decisions that we include on the treatment escalation plan are noted there in the colored boxes that we're talking about the full escalation for want of a better term uh including resuscitation and potential referral to intensive care. We talk about selective interventions in high dependency units or kind of level to care environments or selected interventions, but award ceiling of treatments. And then we we include patient's who are really for palliative care only where symptom control measures only. And then we make a very clear um annotation on the treatment escalation form about whether or not attempt resuscitation should be made in the event of cardiac arrest. But this doesn't replace the national uh DNA CPR form, which is obviously still in use. We include space for the document to be signed by the person completing the form, but also to be countersigned by the senior clinician responsible for the patient. On the reverse of the page, we include a section here for common medical interventions and and we often find that this is actually not filled in in the number of cases, but where it's filled in, it can be really very useful. So, annotating whether or not patient should, for instance, have arterial blood gas sampling. Uh and then a space for free text comments about which interventions would be appropriate or which would be inappropriate. And this is frequently where I would write things like your renal replacement therapy inappropriate or CT scans inappropriate. For instance, we include a section about who the patient who this discussion has been had with. Um And the you have a bit about that but it shouldn't replace conversation still being recorded narratively in the clinical notes and a couple of decision making and communication aids that are included here including the scoring system for the clinical frailty score and the red map guide that Robins already talked us through. Uh And, and this is the iteration of the treatment escalation plan that we have in use currently and it continues to receive very good feedback from our clinical colleagues next slide, please. Um So following on from before when I was mentioning about engagement, so in order to um from the formal audit carried out at the towards the end of last year, how could I keep the momentum going? And so using the model fel improvement in methodology around PDS A, I started work with uh two wards, a university hospital, Mom Clings. And although that seems small, but I find that starting small and being able to tease out all the different little glitches and challenges can then make it much easier for the next two wards in the next two wards, etcetera. Um So thinking about that, um much of it started with observation. So what actually is the activity when it is their opportunities for treatment, escalation? Discussion's within the war processes. So looking at handovers board drowns ward drowns. Um I'm looking at multidisciplinary um discussion's that that happen um identified there's various ward processes. So going from one more to the next, didn't always replicate it in the exact same way. However, I recognized opportunities where a prompt could be taken. Um And that's something that started quite recently um as part of a work through operation flow and certainly driven through the unscheduled care uh demands currently. But the whiteboard um the whiteboard um is led with the ward doctor and there is much discussion And on this, there is tape included. Um And whilst it's part of the conversation, the next stage two actually has the tape been completed. Um seems to be the more difficult element of it. And around that, it's that element of um disparity around whose role it is a to actually commence the form. And as I said, we developed a standard operating procedure. I mean, reiterating that with the multidisciplinary teams that whoever has a concern about a patient's condition has the support of the organization to initiate treatment escalation. Um Again, I mentioned before around version. So I found a several different versions. So again, linking with the board, a clerical staff to ensure that there's the right tool, thinking about visual tools to help um staff to understand. So we did a quick guide um that demonstrates that the process for initiating a treatment escalation. But again, thinking about how we can make it more visual. Um So having some um laminated documents, etcetera next to the, to the whiteboard, um we're now on a cycle four of the PDS A um which is now leading on to the next stage of the conversation. If we can initiate the treatment escalation. What happens after that next slide, please? Thanks. So as Karen said, we've, we've made a lot of progress, but we still have recognized that out abuses still probably suboptimal. And we've also increasingly recognized that there's an element of quality that needs to be considered here that, well, we might have document complete completion as a raw statistic. There's still the risk that some of the processes are still suboptimal and like quality and a recognition they're that they're probably attempt done badly is, is almost certainly worse than not at all. So we spent some time focusing on quality and also about streamlining use and thinking about avoiding repetition and and focusing on making sure that information is available to clinicians at the right place. At the right time. We find that that we have a frequent, a high number of patients who are often using on schedule care repeatedly and might have been through a tep decision making process over and over again and often as unnecessary and sometimes even harmful repetition and this particular risks and and challenges around the interface often between hospital admission and discharge and communication and with primary care. So we're recognizing there that there are some holes and and where we are just now, which is what's driven our next movement, next slide, please. So this is where we've started to introduce the respect process in alongside tepes. So I'll just briefly touch on the respect document. I suspect many people in the audience will know this but respect is a UK wide um initiative and and model and the recommended summary plan for emergency care and treatments and it's very well established process, but it involves a discussion between patient's often their families and the clinicians. Um and it allows a documentation of wishes and recommendations for care in an emergency situation. So the top of the form includes some demographics. And then a key part here is a shared understanding of health and current situation. And what's really important there for me is that, that, that mandates a prognostic conversation between the clinician where you're handing over that information about where they are and then focus on what matters to the patient where their preferences lie, what, what they value most and what they really want to avoid. And then the final part really allows a very, very specific and finessed. Um focusing on, on specific treatment recommendations for use in emergency, including a note there on whether or not resuscitation is to be planned in an emergency situation. So this is the respectful and as I say, we're now bringing this in alongside treatment escalation plans. And with the next slide, Karens going to talk us through how next slide please. Thanks. Um So this slide is it is a demonstration that I had pulled together because recognizing engagement and having the the 1 to 1 conversations I developed this in order to make it a visual tool um to be able to communicate what was in my head and how treatment escalation and how respect as an anticipatory care planning um could work together. The example here in the infographic demonstrates where a digital respect has been completed within the community setting be that in a care home or with the GPU in in someone's own home. However, there has been a call, they attend the hospital through our patient management systems and for track care and clinical portal, there is an alert when the chi is entered into the system that alerts that the first assessing healthcare professional and to recognize that there have been documented in goals of care and a personal wishes um for the patient um that can then demonstrate if there's the appropriateness for admission and or to facilitate that discharge transition back into the community setting. If for admission, there is the recognition that there were am goals of care demonstrated in the process and that then determines the treatment escalation plan. During the the the hospital admission, there is recording share decision conversations and review for the treatment escalation and then ultimately leading towards the discharge, there is a consideration for what treatment escalation plan a goals were put in place and how they link with the original respect process and what changes we are required to be made. Um In Lanarkshire currently, we are still in paper, we're hopefully soon to go live with the digital respect. However, once we are digitally live, the respect process that is updated and refreshed as part of the interim discharge planning um will automatically send a copy through Darkman to the GP practice the G P looking after um and will be accessible through the document process. On two EKGs and through vision that's used in primary care and similarly working alongside um with our other partners such as Scottish Ambulance service and our community district nursing teams, etcetera um for the systems that are used. And the information that was agreed as part of that discharge plan will be accessible for all professionals. But similarly, again, depending on the goals of care that were determined, there may be a subsequent admission that is appropriate, but the levels of treatment will evolve through time as agreed with the professional and the other professional, the patient next light. So just to highlight them that the respect form sits with the patient's wherever the patient would be in the community. Um And, and the respect form can be generated in a variety of different uh kind of settings. As Karen's illustrated that might be at the time of hospital discharge and the patient's going back out into the community community, or it might be when the patient attends a hospital clinic or is seen by a specialist nurse or in, in a different environment. Or for instance, if they're discharged from the hospice or attending a hospice for symptom control reasons, or indeed, in many cases, could be generated in primary care. And ultimately, that reset respect process sits with the patient and the decisions are documented there clearly such that at the time of crisis and an emergency, it can then use to guide decision making. And that might result in a further hospital admission if that's appropriate and in line with what the patient's wishes and and like the outcomes are going to be, or it might often avoid hospital admission, which is a key area for improvement work and might return a patient into an alternative environment. For instance, a hospice of actually, this is a patient approaching the end of life. But ultimately, wherever the patient goes or either if they stay at home, the respect form allows their goals of care to be clear, obviously revisited at the time of crisis, but allows allows those decisions, make decisions made to be clear next slide please. So thinking a bit about that respect form and why we think it's useful in this circumstance. As I said, it really is just about identifying goals of care. It works very well and it in various different settings because it largely relies on free text that allows for a lot of flexibility. I know my colleagues in palliative care might spend an hour with a patient talking through a respect process at the time of discharge from hospice or in my practice, it might just be a five minute addendum to a clinic conversation where we've discussed prognosis, prognosis, goals of care and maybe made some decisions. And often times this is a dynamic thing that might evolve with numerous conversations. And it and for us, it really usefully documents those conversations and that plan and particularly with the digital solution allows that to be held in real time in all of the different settings that needs to be. So it's available to secondary care or to GPS or out of hours. And indeed even hopefully the ambulance service too, next slide, please. So what about tip and respect, how do they work alongside? So Robin's already spoken to this to some extent and, but I'll talk now about our experience. I, I firmly believe that these are not two of the same thing and I think they probably do fit well, the idea that there are two different kinds of footwear, but one for one and one for another and there is an awful lot of overlap. And I can certainly understand the arguments where respect probably does the job of tip. Why would you have, why would you have both my own view is that they do meet slightly different purposes, particularly in emergency circumstances? It's absolutely essential that there's real clarity about where the escalation decisions lie. So that if you are the medical junior doctor at three in the morning and somebody's, you know, the emergency buzzes going and you need to make a decision quickly, you maybe don't have time to run through all of the detailed free text that might be included in a, in a respect form. But you can quickly see all this patient is someone who's been deemed for full escalation. It's time to call my intensive care colleagues you and the quick ease of use that the treatment escalation plan allows. And it also goes into many very specific hospital interventions um that that, that are really required in hospital but often very meaningless to primary care colleagues. Whereas respect is much more appropriate for that setting where you can make a bespoke plan relative to the individual depending on their stage of illness. And it might be something that's relevant for the coming days or weeks or possibly even for the months and years beyond. And particularly given the functionality we're going to hear about shortly. The respect uh digital platform is going to enable this um tool to use in a very practical way. Next slide, please. So where are we now? So in Lanarkshire colleagues, Doctor Cook, um Susan Cook, one of our palliative care colleagues has really paved the way with respect in N H S Lanarkshire and it's now standard practice for patients who are being discharged from hospice is to have respect forms completed at the time of their discharge. Clearly discussing their goals of care and future plans. Primary care colleagues have really driven um improvement work looking at care home residents, you know, in many centers will all have respect plans. Um And we recently are developing a test of change and an acute setting using a renal service where we have lots of frail, multi morbid patient's and and often very invasive, sometimes very burdensome interventions and a large number of unscheduled care admission's with lots of in patient's is a really useful opportunity for us to develop the combination of using TEP and respect in these patient's. And so this is where we are now in N H S Lanarkshire. Um And, and hoping to see that develop as time goes on next slide, please. I'm just very briefly going to run through a case discussion just to illustrate some of the points that we've made here. Many of them, hopefully fairly straightforward. So this is a familiar case for many of us in the receiving units. So I'm a multi morbid 81 year old patient where the background of hypertension diabetes, airways disease who had COVID in November hasn't really got out the bit increasingly dependent. Now, housebound, losing significant amount of weight. And prior to her presentation had a clinical frailty score of six and at the front door, she's unwell with a new score of seven, uh a diagnosis of uh of sepsis. Next slide, please. So this is a point where the team have an appropriate prognostic conversation with the patient and family. We identify that she's frail and poorly in the background and that she's currently really physiologically challenged. And there's a discussion about goals of care and what we're aiming for here and some shared decision makings establishing that we're not gonna invasively investigate a weight loss and while she's being treated aggressively, but at award ceiling of treatment, there's gonna be A D any CPR and we're not going to be taking things further than that with antibiotics, fluids and oxygen. Next slide, please. So all of that was documented on the in hospital treatment escalation plan and as time has gone on, the patient has as many do survived acute sepsis issues has gone through a process of rehabilitation but has been left with significant functional impairment and it's now getting to the stage of hospital discharge and this is an opportunity for a further conversation. So this is where I would have a reflective conversation with the, with the patient and ideally her family, talking about the treatment she's been through and what she found. And in this case, she found that, you know, while she was glad to have survived, she found the repeated any puncture necessary to keep her on IV antibiotics was really torture for her. And while she was up for it at the time, now that she's been left with significant functional impairment, she doesn't really fancy going through any of that again. And so we're able to make some decisions regarding her future care. We will keep the D N A C P R and that will remain in place and we'll communicate that into primary care. She's making a clear decision at this stage not to be re admitted in an emergency and has made some decisions about her preferred place of death and how, how she would like to be cared for as she comes to the end of her life. And all of this at this stage is now documented in the respect form which will be available in primary care, available on clinical portal for other secondary care clinicians. But also crucially, we recognize that this is a dynamic and flexible thing that allows for adaptation. As time goes on, we might find that she gets home and thrives. In which case, some of the decisions that she may she has made may need to be revisited and with the digital platform that will be uh readily possible. So here a clear illustration then of what we've used the treatment escalation plan at the point of presentation, acute physiological threat, where we need to have some very clear specifics about how we look after in hospital. She's come through that admission but remains unwell and frail with very high risk of further deterioration and, and the necessity for us to document future goals of care and future care plans and the respect form for us works very well for this. Um And so making the making it easier to do the right thing I think is Robin put next like please. So thinking about what our next steps for treatment, escalation and respect. So obviously, for Lanarkshire and fundamentally to go live with our digital respect and and enjoy and join forth Valley and Teesside in Western Isles and borders who have have gone live digitally. Um The relevance of that obviously is fundamentally the connection and the connection for all healthcare professionals um to do the right thing for that person, irrespective of, of where they are being in a hospital setting or at home or in a care home. Um Wyden R N N map engagement. And the reason for that is we can have recognized that our end maps tend to be a more static workforce, recognizing that trainees obviously rotate, they don't always receipt within our our own board and they will move around. And so therefore, if we can heighten um the discussion prompts around RM maps who ultimately will be the prompts with their, their medical colleagues to ensure that the right documentation is with the right patient for the right treatment at the right time. Um And thinking of that where we have um we have an alert uh that will recognize if there's a D any CPR, if there's a respect in place, we would also by not think digital tip where that would also link. Um And all the relevant documentation is together. Um The next slide please, Steven is just to quickly acknowledge that obviously, Jack and I are here presenting today, but we wouldn't have been able to do this without obviously working very closely with her colleagues, Doctor Susan Cook, Doctor Calvin Lightbody. Obviously, um what Professor Robin Taylor had initiated initially in, in Lanarkshire and with the support of our realistic here healthcare group for Lanarkshire that has given us full support in order to take this forward. Um And the last slide was just to, to, to ensure that we had encompassed what we'd set out to do the presentation so we can end the slides there. Stephen. Thank you. Excellent. Thank you guys very much for your presentation. Um Um Very good as, as always, um I have a few questions, I'll take a few questions from the chat as well. So if you want to add in some more questions there, um so we can interact with the speakers. Um That'll be amazing. Um I guess going back to the implementation of things, implementation of tepes. Um What was the, do you have like a top three? I'd say a top 10, but time is limited. A top three things that pushed implementation forward. What are the sort of three things that jumped out to you? I suppose um a key point in feedback has been around from work force feedback from workforce about fear of doing the wrong thing and not knowing what the right thing is to do and, and it's been spoken of the three AM situation in the morning um and the difficulty having gone through the case note, mortality of you. Um It's disheartening when you're reading a repetitive entries into case notes where at the same time you're reading around a deterioration that's happening or futile treatment that that is being invested in for me thinking about it from the realistic medicine point of view and thinking about the shared decision making, about reducing harm. Um Now thinking about our value based approach, um the feedback actually from our workforce is important and it's relevant and, and, and if we can't act on that in order to support them with the implementation of uh a process that is reasonably simple. Um And actually again, in the case note, review, when there is a treatment escalation in place, you know exactly what the plan is for that, that patient. So um for me that is that is the key point. Um and part particularly of considering over the last few years, um staff health and well being um is a very important factor in order to retain our workforce. And therefore, if we can reduce the anxiety's associated with that, then doing the right thing is having tip. There is a question from Connor in the chat that says that if you filled in properly completed respect form, um Could you just scrap tips? Um because does that not just provide the guidance to the team about the sort of acutely deteriorating patient? Um And would that not just help with less paperwork and duplication or do you think that the TEP adds something additional? Yes. So I think that's a really good question and I don't, I don't profess to have the expert answer in this. And I think we have to be realistic about where our background is in N H S Lanarkshire and that we have your many, many years of experience, you're born through really hard labor and intense intervention, getting tep rolled outs. And I think even just looking at the challenges have been associated with different versions of Tep and, and iterations changing the way tepes been practiced. I think there'll be a real risk that any major change. You know, for instance, if we got rid of Tep and replace it with respect, I think that would, that would be a real risk. That said even if I was given a blank slate and kept didn't exist in Lanarkshire, I would still opt to the model we have with Tepfer in patient's and respect for outpatients. And I think for me, the most crucial aspect of that is it necessitates the second conversation. You might have that goals of care, prognostic conversation at the beginning when the patient's first admitted, and you might establish goals of care in the treatment escalation plan then, but that needs to be translated into something meaningful for the patient, their family and for clinicians in the community at the time of discharge. And so actually having the to having tipped for that inpatient stay and then respect means that that there's a, you know, there's a necessary distinction. I think there'll be a real risk that you might have a respect form or whatever, whatever it is filled in at the front door that doesn't get considered again at the very end. And then you still are left in no man's land without people knowing what the goals okay are at the time of discharge and, and respect, I think fills that hole and it also affords the flexibility. And I think looking at the comments of people who you and speaking to colleagues who do work in environments by respect is used in that acute setting. I think the key component of that question is if the respect form is filled in correctly. So that that if is quite a big if and if you're the med reg at three in the morning and someone's got a news of 15 and you and the intensive just need to make a decision quickly about whether or not they're gonna get tubes. You really need to, you need to, you need not to spend 15 minutes going through the detail of the free text narrative and the respect from you really need to see that tick box. What, what are you aiming for in, in this admission? And that's where I think the tep afford that emergency decision making. The respect sometimes doesn't allow it unless it's done properly. But the sad thing is we know that it isn't done properly all of the time. Maybe a quick question. There's um the interface between tepes and D N A C P R and I supposed respect and D N A C P R, the question um wasn't Connor, it was um it was further up, sorry. Was Alice who said if you come in with respect form that says D N A um CPR but no official read form. Should the patient be resuscitated? Um How did the two go together, I suppose is the question? Yes, I think at the moment I think this is a paperwork thing essentially. I think if you've documented a decision and a document and a discussion and it's clear that a DNA CPR is in existence, then, then in my own practice would be just to translate that into a rewritten red form. A D N A C P R form at the front door. Even if you, if the form is not there, I'm hopeful that in time, the digital solutions here are gonna gonna make the difference. And I think respect digital platform is really going to allow for that particularly because it's going to be flexible and dynamic. It's gonna allow for new versions, new iterations of those cons negotiations, you know. So there's not a question of whether or not the D N A C P R has been revoked at the point of previous discharge where we are currently, we have a separate D N A C P R decision in line with N H S Scotland policy. But but we very firmly fixed with the idea that no DNA CPR without a TEP. So in, in patient, should all have a D N A C P R with a TEP form and, and where did any CPR has been agreed either in the community or in hospital? They should still have the D any CPR form. I think for Scotland, we need to recognize currently that the red DNA CPR remains a legal document. So as Jack has, has mentioned, um if it is documented within the respect, but there's no visible red form, then one should be initiated because it is a legal process currently. Yeah, I think we have the same thing and uh that uh if you are doing a D N A C P R for, then a TEP gives you the information up to that Ian has put in the chat. The D N A C P R is like the full stop. But the um at the end of a full paragraph of the TEP form it um if, if that's the appropriate um direction for for that patient, I'm kind of looking through the questions as I come along, they're coming in thinking, I noticed there was a question Stephen around patient or family perspective. We have captured through the testing of, of respect from patients' and, and families and from staff. And the feedback has been positive to the extent where patient's have commented that they feel the involvement in the respect process can reduce burden on their family to be making decisions about them and perhaps not always with them. Um And likewise, for families to say. Um This is the first time we've had this open discussion, it was difficult, however, very helpful. Now, I know what my parents, relatives wishes are similarly for staff who have experience of working with the my A C P that continues but was in existence before that was quite a hefty bulky document. And they feel that the respect process is captures in essence what is required in the event of the next emergency admission um or the next emergency situation. Um And it's been helpful and the flow of it is quite um streamlined and actually has AIDS and Susan Cooker own um consultant who kind of started to lead on the respect process had said and she's open label share that she thought she was quite good and actually she's changed her practice um since using respect. Uh So feedback has been positive, particularly from patients' and their families so much so that certainly much of the evaluation has been a yes or no or a tick box. But the free text that we've received back in return has been um quite helpful. I have, I have another question for you. I'm maybe gonna leave it for the panel discussion the end, but I'll post it to you just so that you can think about it. Um And it's about that interface between tepes and um A cps um or respect going into primary care and the thoughts of the primary care team around that because I think those interfaces are very important and it's something that you guys are a way ahead of us on up in Grampian, especially Calvin like body. One of your colleagues um saying from a acute admission perspective respects a little bit too vague. Um uh The tep odds clarity, which I think is Robin chatting with the different para shoes. Um um The Christians put something about when respect and captured digital, digitalized and this is a good segue into the next speaker. Um We will see about that and um, uh Connor is at the start of putting things into, into place. Um, and Donna's, um their tips have a space for discussion's can be documented with the family and I think that is the crux of it having that aims a treatment discussion with the patient, their families and their carers. I'd like to thank you to very much for your excellent presentation. You're gonna stick around to the panel discussion to answer this opportunity for more questions. Then Robbins appeared on the screen to tell me I'm running behind. Uh Robin in.