Julia Walsh

In the UK, the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is a widely used process, designed to facilitate shared decision-making between a clinician and a patient or, if the patient lacks capacity to participate in the conversation, a person close to the patient. A key outcome of the ReSPECT process is a set of recommendations, recorded on the patient-held ReSPECT form, that reflect the conversation. In an emergency, these recommendations are intended to inform clinical decision-making, and thereby enable the attending clinician—usually a general practitioner (GP) or paramedic—to act in the patient’s best interests. This study is the first to explore the extent to which ReSPECT recommendations realise their goal of informing best interests decision-making in community contexts. Using a modified framework analysis approach, we triangulate interviews with patients and their relatives, GPs and nurses and care home staff. Our findings show that inconsistent practices around recording patient wishes, diverging interpretations of the meaning and authority of recommendations and different situational contexts may affect the interpretation and enactment of ReSPECT recommendations. Enacting ReSPECT recommendations in an emergency can be fraught with complexity, particularly when attending clinicians need to interpret recommendations that did not anticipate the current emergency. This may lead to decision-making that compromises the patient’s best interests. We suggest that recording patients’ values and preferences in greater detail on ReSPECT forms may help overcome this challenge, in providing attending clinicians with richer contextual information through which to interpret treatment recommendations.

In twelfth-century Europe schools flourished in many centres. There were schools in monasteries and cathedrals, primarily for the education of monks and priests but often open also to laymen. In Italian towns, especially, there were lay schools teaching law and commercial skills to fee-paying students. In France, especially, also in England and other countries, there were schools for feepaying students of the liberal arts. The traditional list of the liberal arts included seven: grammar, logic and rhetoric (the "trivium"), and arithmetic, geometry, astronomy and music (the "quadrivium"): most of the schools we're talking about taught the trivium, grammar, logic and rhetoric. These three disciplines in one way or other taught language skills; they were sometimes called the artes sermocinales. Students who had completed these "trivial" studies sometimes moved on to theology, or sometimes set up as teachers themselves of grammar, logic and rhetoric. Some students travelled from country to country looking for a good school, and sometimes made their living for a while by teaching before becoming students again.