Patient and relative experiences of the ReSPECT process in the community: an interview-based study.

BACKGROUND: The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) was launched in the UK in 2016. ReSPECT is designed to facilitate meaningful discussions between healthcare professionals, patients, and their relatives about preferences for treatment in future emergencies; however, no study has investigated patients' and relatives' experiences of ReSPECT in the community. OBJECTIVES: To explore how patients and relatives in community settings experience the ReSPECT process and engage with the completed form. METHODS: Patients who had a ReSPECT form were identified through general practice surgeries in three areas in England; either patients or their relatives (where patients lacked capacity) were recruited. Semi-structured interviews were conducted, focusing on the participants' understandings and experiences of the ReSPECT process and form. Data were analysed using inductive thematic analysis. RESULTS: Thirteen interviews took place (six with patients, four with relatives, three with patient and relative pairs). Four themes were developed: (1) ReSPECT records a patient's wishes, but is entangled in wider relationships; (2) healthcare professionals' framings of ReSPECT influence patients' and relatives' experiences; (3) patients and relatives perceive ReSPECT as a do-not-resuscitate or end-of-life form; (4) patients' and relatives' relationships with the ReSPECT form as a material object vary widely. Patients valued the opportunity to express their wishes and conceptualised ReSPECT as a process of caring for themselves and for their family members' emotional wellbeing. Participants who described their ReSPECT experiences positively said healthcare professionals clearly explained the ReSPECT process and form, allocated sufficient time for an open discussion of patients' preferences, and provided empathetic explanations of treatment recommendations. In cases where participants said healthcare professionals did not provide clear explanations or did not engage them in a conversation, experiences ranged from confusion about the form and how it would be used to lingering feelings of worry, upset, or being burdened with responsibility. CONCLUSIONS: When ReSPECT conversations involved an open discussion of patients' preferences, clear information about the ReSPECT process, and empathetic explanations of treatment recommendations, working with a healthcare professional to co-develop a record of treatment preferences and recommendations could be an empowering experience, providing patients and relatives with peace of mind.

Maternal mental health: a key area for future research among women with congenital heart disease.

In this viewpoint, we respond to the recently published national priorities for research in congenital heart disease (CHD) among adults, established through the James Lind Alliance Priority Setting Partnership, with specific attention to priority 3 (mental health) and priority 5 (maternal health). Our recent policy impact project explored how maternal mental health is currently addressed in adult congenital heart disease (ACHD) services in the National Health Service, identified gaps and discussed possible ways forward. Our multidisciplinary discussion groups, which included women with lived experience of CHD and pregnancy, cardiology and obstetrics clinicians and medical anthropologists, found that while pregnancy and the postnatal period increase the mental health challenges faced by women with CHD, current services are not yet equipped to address them. Based on this work, we welcome the prioritisation of both mental health and maternal health in ACHD, and suggest that future research should focus on the overlaps between these two priority areas.

A long-term follow-up of treatment for young children with obesity: a randomized controlled trial.

BACKGROUND: Early childhood obesity interventions supporting parents have the largest effects on child weight status. However, long-term follow-ups are lacking. OBJECTIVE: To examine weight status 48 months after obesity treatment initiation for 4- to 6-year-olds. METHODS: 177 families were recruited to the More and Less study, a 12-month randomized controlled trial (RCT) conducted in Sweden (2012-2017); 6 children were excluded due to medical diagnoses. Thus, 171 families (non-Swedish origin 59%, university degree 40%) were eligible for this 48-month follow-up with modified intention-to-treat (n = 114 had 48-month data, n = 34 dropped out, n = 23 lost to follow-up). The RCT compared 3 treatment approaches: a 10-week parent support program (1.5 h/w) with follow-up booster sessions (PGB) or without (PGNB), and standard outpatient treatment (ST). Treatment effects on primary outcome (BMI-SDS) and secondary outcomes (BMI, %IOTF25 i.e., the distance, in percent, above the cut-off for overweight) were assessed. Clinically significant reduction of BMI-SDS (≥0.5) was assessed with risk ratio. Sociodemographic factors and attendance were examined by three-way interactions. RESULTS: After 48 months (mean 50 months, range 38-67 months) mean (95% CI) BMI-SDS was reduced in all groups: PGB -0.45 (-0.18 to -0.73, p < 0.001), PGNB -0.34 (-0.13 to -0.55, p < 0.001), ST -0.25 (-0.10 to -0.40, p < 0.001), no significant difference between groups. A clinically significant reduction of BMI-SDS ≥ 0.5 was obtained in 53.7% of PGB which was twice as likely compared to ST, 33.0%, RR 2.03 (1.27 to 3.27, p = 0.003), with no difference to PGNB, 46.6% (p = 0.113). %IOTF25 was unchanged from baseline for PGB 4.50 (-1.64 to 10.63), and significantly lower compared to ST 11.92 (8.40 to 15.44) (p = 0.043). Sociodemographics or attendance had no effect. CONCLUSION: The intensive parent-support early childhood obesity intervention led to better weight status outcomes over time, though BMI-SDS alone did not reflect this. Further research should investigate how to assess weight changes in growing children. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, NCT01792531 .

Experiencing good results promotes positive feelings to high-intensity exercise among young adults: A qualitative study.

Introduction: From a public health perspective, it is important to gain more insight into how people can be motivated to maintain effective exercise routines. It is a common belief that moderate-intensity exercise is more pleasant and enjoyable than high-intensity training. This study aims to provide insight into (1) participants' expectations and preferences for training intensity prior to training, (2) how longer-term participation affect participants' experience of endurance training with continuous moderate-intensity training and high-intensity interval training. Materials and methods: A total of 22 participants (14 women and eight men) between the ages of 21-30 volunteered for participation. Participants were randomized and divided into two equal groups. A total of 17 participants, nine women and eight men, completed the study. One group did moderate-intensity longer-lasting training and the other did high-intensity interval training. All participants completed three training sessions per week for 8 weeks. Semi-structured interviews were conducted with each participant before and after completing the training intervention. Data was analyzed using thematic analysis. This study is a part of a larger study evaluating and comparing the effects on endurance capacity of high-intensity interval training and moderate-intensity training. Physiological data are previously published. Results: The results describe participants expectations prior to training, and how they experienced the actual training. The overall experience of training comprises several factors that work together. Both expectations and actual experiences (e.g., of physical pleasantness or unpleasantness, of positive or negative emotions, and of actual results from the training) contribute to the participants' overall experience of exercise. Conclusion: The major finding is that improved physical fitness was a stronger motivator than feelings of pleasantness. Experiencing good results seemed to downplay feelings of unpleasantness and reinforce positive feelings toward exercise. Lack of results reinforce negative feelings toward exercise. Participants reported high-intensity exercise as more unpleasant and exhaustive, but the interval training group were more satisfied and experienced the training as more motivating.

Parents' experiences following conversations about their young child's weight in the primary health care setting: a study within the STOP project.

BACKGROUND: In primary healthcare, conversations between clinicians and parents about young children's overweight are key to providing support and initiating weight management. However, given the sensitivity of this topic, these conversations are difficult for both clinicians and parents and are sometimes delayed or avoided. To understand the emotional impact of these conversations, this study aims to shed light on parents' experiences following conversations with primary care nurses about their child's overweight. METHODS: Participants were recruited through a childhood obesity randomized controlled trial (RCT) conducted in Sweden. Telephone-based semi-structured interviews were conducted with 17 parents (mean age 40; the majority were women (n = 12/17), had a university degree (n = 14/17) and were born in Sweden (n = 13/16)). Their children were between 3 and 7 years old (mean age 4.8 years) with overweight (n = 7) or obesity (n = 10). The interviews were recorded, transcribed, and analyzed using thematic analysis. RESULTS: Two main themes were developed. Theme 1, 'Receiving the overweight/obesity diagnosis', explores parents' reactions to the conversation with the primary care nurse. Depending on how the nurse presented the topic, conversations either fostered an alliance between the parent and the nurse, encouraging parents to reflect and develop insights about the child's and the family's needs (subtheme Conversations that empower), or felt limited, uncomfortable, or belittling (subtheme Conversations that provoke resistance). Theme 2, 'Parenting a child with a formal diagnosis of obesity', explores challenges parents faced following the weight conversations, including managing their own feelings and concerns (subtheme Fear of transferring weight anxiety), dealing with others' reactions (subtheme Involve family and manage surroundings) and asking for and receiving support from health care professionals (subtheme Obtain support from health care professionals). CONCLUSIONS: While conversations with primary care nurses about children's weight were often emotional, most parents felt these conversations were ultimately helpful, as they encouraged them to enact positive lifestyle changes. Importantly, when nurses initiated conversations in a responsive, non-blaming way, inviting parents to reflect on their situation, parents felt more supported and empowered. These findings convey the importance of providing communication skills training to pediatric healthcare professionals, with particular focus on childhood overweight and obesity. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT03800823 ; 11 Jan 2019.

Implementation of ReSPECT in acute hospitals: A retrospective observational study.

AIMS: To evaluate, in UK acute hospitals, the early implementation of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT), which embeds cardiopulmonary resuscitation (CPR) recommendations within wider emergency treatment plans. To understand for whom and how the process was being used and the quality of form completion. METHODS: A retrospective observational study evaluating emergency care and treatment planning approaches used in acute UK hospitals (2015-2019), and in six English hospital trusts the extent of ReSPECT use, patient characteristics and completion quality in a sample 3000 patient case notes. RESULTS: The use of stand-alone Do Not Attempt Cardiopulmonary Resuscitation forms fell from 133/186 hospitals in 2015 to 64/186 in 2019 (a 38% absolute reduction). ReSPECT accounted for 52% (36/69) of changes. In the six sites, ReSPECT was used for approximately 20% of patients (range 6%-41%). They tended to be older, to have had an emergency medical admission, to have cognitive impairment and a lower predicted 10 year survival. Most (653/706 (92%)) included a 'not for attempted resuscitation' recommendation 551/706 (78%) had at least one other treatment recommendation. Capacity was not recorded on 13% (95/706) of forms; 11% (79/706) did not record patient/family involvement. CONCLUSIONS: ReSPECT use accounts for 52% of the change, observed between 2015 and 2019, from using standalone DNACPR forms to approaches embedding DNACPR decisions within in wider emergency care plans in NHS hospitals in the UK. Whilst recommendations include other emergencies most still tend to focus on recommendations relating to CPR. Completion of ReSPECT forms requires improvement. STUDY REGISTRATION: https://www.isrctn.com/ISRCTN11112933.

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

Background: As an emergency care and treatment planning process (ECTP), a key feature of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is the engagement of patients and/or their representatives in conversations about treatment options including, but not limited to, cardiopulmonary resuscitation (CPR). However, qualitative research suggests that some ReSPECT conversations lead to partial or no decision-making about treatment recommendations. This paper explores why some ReSPECT conversations are left incomplete. Methods: Drawing on observation and interview data collected in four National Health Service (NHS) hospital sites in England, this paper offers an in-depth exploration of six case studies in which ReSPECT conversations were incomplete. Using thematic analysis, we triangulate fieldnote data documenting these conversations with interview data in which the doctors who conducted these conversations shared their perceptions and reflected on their decision-making processes. Results: We identified two themes, both focused on 'mismatch': (1) Mismatch between the doctor's clinical priorities and the patient's/family's immediate needs; and (2) mismatch between the doctor's conversation scripts, which included patient autonomy, the feasibility of CPR, and what medicine can and should do to prolong a patient's life, and the patient's/family's understandings of these concepts. Conclusions: This case study analysis of six ReSPECT conversations found that mismatch between doctors' priorities and understandings and those of patients and/or their relatives led to incomplete ReSPECT conversations. Future research should explore methods to overcome these mismatches.

Children's experiences of meals after obesity treatment: a qualitative follow-up four years after a randomized controlled trial.

BACKGROUND: The practice of eating together, commensality, is rarely explored in the context of childhood obesity treatment. This is noteworthy given long-standing debates about the physical, psychosocial, and societal benefits of meals, especially family meals. Moreover, as children with obesity experience weight bias and stigma both within and outside the home, it is important to examine meals as a locus of social exchange around food and the body. Our study is based on the premises that eating together (i) matters and (ii) occurs in different environments with diverse social organization, where food-related interactions create varying arrangements of individuals, groups, their statuses, and their actions. METHOD: The study explores children's experiences of meals in different social contexts. Thirty-two children (age 8-10 years) living in Sweden were interviewed, 4 years after they entered an obesity intervention trial. Thematic analysis was applied to the data. RESULTS: We thematized three meal types, with each meal type having two subthemes: (i) "The family meal", with "Shared routines, rituals, and rules" and "Individual solutions and choices"; (ii) "The school meal", with "Rules and norms of the school" and "Strategies of the child"; and (iii) "The friend meal", with "Handling food that was disliked" and "Enjoyment of food". These three different meal types carried different experiences of and knowledge about how they were socially organized. CONCLUSIONS: While the children spoke about the family and school meals as meaningful, the friend meal stood out as particularly positive. Contrary to our expectations, the children did not express experiences of weight bias or obesity stigma around meals, nor did they speak negatively about parental control of their food intake. Our findings, especially regarding the friend meal, have implications for further research into commensality and social influences on eating among children with obesity, from early childhood into adolescence.

Caring in the silences: why physicians and surgeons do not discuss emergency care and treatment planning with their patients - an analysis of hospital-based ethnographic case studies in England.

BACKGROUND: Despite increasing emphasis on integrating emergency care and treatment planning (ECTP) into routine medical practice, clinicians continue to delay or avoid ECTP conversations with patients. However, little is known about the clinical logics underlying barriers to ECTP conversations. OBJECTIVE: This study aims to develop an ethnographic account of how and why clinicians defer and avoid ECTP conversations, and how they rationalise these decisions as they happen. DESIGN: A multisited ethnographic study. SETTING: Medical, orthopaedic and surgical wards in hospitals within four acute National Health Service trusts in England. PARTICIPANTS: Thirty-four doctors were formally observed and 32 formally interviewed. Following an ethnographic case study approach, six cases were selected for in-depth analysis. ANALYSIS: Fieldnote data were triangulated with interview data, to develop a 'thick description' of each case. Using a conceptual framework of care, the analysis highlighted the clinical logics underlying these cases. RESULTS: The deferral or avoidance of ECTP conversations was driven by concerns over caring well, with clinicians attempting to optimise both medical and bedside practice. Conducting an ECTP conversation carefully meant attending to patients' and relatives' emotions and committing sufficient time for an in-depth discussion. However, conversation plans were often disrupted by issues related to timing and time constraints, leading doctors to defer these conversations, sometimes indefinitely. Additionally, whereas surgeons and geriatricians deferred conversations because they did not have the time to offer detailed discussions, emergency and acute medicine clinicians deferred conversations because the high-turnover ward environment, combined with patients' acute conditions, meant triaging conversations to those most in need. CONCLUSION: Overcoming barriers to ECTP conversations is not simply a matter of enhancing training or hospital policies, but of promoting good conversational practices that take into account the affordances of hospital time and space, as well as clinicians' understandings of caring well.

Material Environments and the Shaping of Anorexic Embodiment: Towards A Materialist Account of Eating Disorders.

Anorexia nervosa is a paradoxical disorder, regarded across disciplines as a body project and yet also an illness of disembodied subjectivity. This overlooks the role that material environments-including objects and spaces-play in producing embodied experiences of anorexia both within and outside treatment. To address this gap, this paper draws together two ethnographic studies of anorexia to explore the shared themes unearthed by research participants' engagements with objects that move across boundaries between treatment spaces and everyday lives. Demonstrating how the anorexic body is at once both phenomenologically lived and socio-medically constituted, we argue that an attention to materiality is crucial to understanding lived experiences. A materialist account of anorexia extends the literature on treatment resistance in eating disorders and offers a reconceptualisation of 'the body in treatment', showing how  objects and spaces shape, maintain, and even 'trigger' anorexia. Therefore, against the background of the high rates of relapse in eating disorders, this analysis calls for consideration of how interventions can better take account of eating disordered embodiment as shaped by material environments.

"Writing nutritionistically": A critical discourse analysis of lay people's digital correspondence with the Swedish Food Agency.

This article analyzes lay people's use of nutritionistic discourse in written correspondence with the Swedish Food Agency, an authority responsible for dietary advice. Examining 60 food related written digital messages, we apply a critical discourse analysis to parse the lexical items and grammar people use when constructing "food" in scientific terms. The findings show how message writers place nutrients at the discursive center. Message writers' grammatical constructions instrumentalize food and eating. This is reinforced by the message writers' frequent use of terms that indicate preciseness, such as numbers and amounts. Messages therefore emphasize the what, but not the how, of eating, implying a focus on food as subject to regulation and control. As such, eating is discursively reduced to an act of ingesting nutrients that can be decontextualized and managed in isolation-as entities to increase or avoid separately. These discursive features preclude the conceptualization of food choice and eating as subjective experiences of feelings, taste, and tradition.

How Do Interpersonal Relationships Affect Children's Weight Management? A Qualitative Analysis of Parents' Long-Term Perceptions after Obesity Treatment.

Background: Childhood obesity interventions are particularly effective during the preschool age, but little is known about parents' long-term perceptions of weight management. This study explores how parents perceive the influence of interpersonal relationships on their children's eating and physical activity 4 years after participating in a randomized controlled trial. Bronfenbrenner's ecological systems theory frames this study, with the child's environment conceptualized as interlocking microsystems that affect weight management. Methods: Interviews were conducted with 33 parents (85% mothers, 48% with university degree) of 33 children [mean age 9.3 (standard deviation 0.7), 46% girls] from Stockholm, Sweden. Interviews were analyzed using thematic analysis, focusing on parents' perceptions of interpersonal relationships: family, relatives, other children, preschool/school staff, and health care practitioners. Results: Two main themes were developed: (1) Discouragement, with the subthemes Conflicting rules and Social comparison, and (2) Support and understanding, with the subthemes Teamwork and Shared responsibility and continuity of care. Parents perceived children's weight management as a continuous orchestration of different influences across social spheres. Years after obesity treatment, parents struggled to maintain the child's healthy routines outside the home. However, when siblings, grandparents, teachers, and friends' parents acted supportively, routines were easier to maintain. Conclusions: The findings suggest that each microsystem in a child's environment has important influence on weight management, such that, as children grow older, children's lifestyles cannot be managed by parents alone. To facilitate weight management, more people in the child's environment should be involved early in the treatment process, and continued professional support should be offered to parents.

How active can preschoolers be at home? Parents' and grandparents' perceptions of children's day-to-day activity, with implications for physical activity policy.

BACKGROUND: The importance of physical activity in early childhood for establishing long-term health is well understood, yet with the exception of recent WHO guidelines, public health initiatives rarely focus on children below school age. Moreover, little is known about how domestic spaces and day-to-day caring activities influence preschool-age children's physical activity. To examine this, we explore caregivers' perceptions of young children's activities within and outside the home, and we consider how lived experiences of caregiving align (or not) with current physical activity policy. METHODS: Semi-structured interviews with 49 parents and grandparents from 16 families were conducted in Oregon, USA; each family had a child aged 3-5 years. Questions focused on caregivers' perceptions of and involvement with children's body weights, activities, and food practices. The interviews were analysed using thematic analysis. Our analysis drew on a materialities framework, attending to relationships between children, caregivers, spaces in and around the home, and everyday activities. RESULTS: Four themes were developed: appropriateness of outside versus inside spaces for physical activity; making accommodations for physical activity in the home; active spaces of care, referring to relationships among space, activity type, and caregiver attention; and mundane movement, or the low-intensity movement of everyday life. Together, the results highlight that children's day-to-day activities cut across a spectrum of movement, mediated by available spaces and caregiving affordances. CONCLUSIONS: Attending to the full spectrum of children's movements highlights how children's activities interlink with family routines, available indoor and outdoor spaces, and the intended uses of these spaces. These interplays between space, care, and physical activity enacted at the household level should inform an integrated, systems-level public health approach to increasing health and well-being for preschool-age children. Suggestions for improvement include coordinating policy development across multiple fields (e.g., housing design, urban planning) that structure the activities of children and their caregivers across 'home' and 'outside' spaces.

Associations of preschoolers' dietary patterns with eating behaviors and parental feeding practices at a 12-month follow-up of obesity treatment.

Although dietary patterns are key to the management of childhood obesity, they are rarely assessed and thus poorly understood. This study examines preschoolers' dietary patterns and correlates 12 months after the start of obesity treatment (n = 99, mean age 5.2 years, 52% girls). A food frequency questionnaire (FFQ), the Child Eating Behavior Questionnaire (CEBQ), Child Feeding Questionnaire (CFQ) and Lifestyle Behavior Checklist (LBC) were answered by parents to assess children's food intake, eating behaviors, parental feeding practices, and obesity-related behaviors, respectively. Principal component analysis identified dietary patterns based on FFQ data. Through multiple linear regressions we examined correlations between a healthy (HD) and a less healthy (LHD) dietary pattern and mean scores of the CEBQ, CFQ, LBC scales as well as BMI z-scores. The reported intake of items in the LHD decreased after treatment while no differences were found for the HD. Children's eating behaviors, in particular food fussiness, showed consistent associations with diet (b = -0.39, 95% CI -0.63, -0.14 for HD and b = 0.41, 95% CI 0.15, 0.66 for LHD). Feeding practices and obesity-related behaviours were weakly associated with the dietary patterns (HD and Monitoring: b = 0.36, 95% CI 0.09, 0.62; LHD and Screen time b = 0.08, 95% CI 0.01, 0.15). Among the measured variables, eating behaviors had the largest impact on children's dietary patterns. The LHD was associated with a higher BMI z-score but no associations were found between changes in LHD intake and changes in BMI z-scores. Our findings suggest that decreasing food fussiness in children with obesity is key to positive dietary changes. Assessment of children's eating behaviors can help tailor dietary advice and provide support for families of children with obesity.

Parenting and childhood obesity: Validation of a new questionnaire and evaluation of treatment effects during the preschool years.

OBJECTIVES: Parenting is an integral component of obesity treatment in early childhood. However, the link between specific parenting practices and treatment effectiveness remains unclear. This paper introduces and validates a new parenting questionnaire and evaluates mothers' and fathers' parenting practices in relation to child weight status during a 12-month childhood obesity treatment trial. METHODS: First, a merged school/clinical sample (n = 558, 82% mothers) was used for the factorial and construct validation of the new parenting questionnaire. Second, changes in parenting were evaluated using clinical data from the More and Less Study, a randomized controlled trial (RCT) with 174 children (mean age = 5 years, mean Body Mass Index Standard Deviation Score (BMI SDS) = 3.0) comparing a parent support program (with and without booster sessions) and standard treatment. Data were collected at four time points over 12 months. We used linear mixed models and mediation models to investigate associations between changes in parenting practices and treatment effects. FINDINGS: The validation of the questionnaire (9 items; responses on a 5-point Likert scale) revealed two dimensions of parenting (Cronbach's alpha ≥0.7): setting limits to the child and regulating one's own emotions when interacting with the child, both of which correlated with feeding practices and parental self-efficacy. We administered the questionnaire to the RCT participants. Fathers in standard treatment increased their emotional regulation compared to fathers in the parenting program (p = 0.03). Mothers increased their limit-setting regardless of treatment allocation (p = 0.01). No treatment effect was found on child weight status through changes in parenting practices. CONCLUSION: Taken together, the findings demonstrate that the new questionnaire assessing parenting practices proved valid in a 12-month childhood obesity trial. During treatment, paternal and maternal parenting practices followed different trajectories, though they did not mediate treatment effects on child weight status. Future research should address the pathways whereby maternal and paternal parenting practices affect treatment outcomes, such as child eating behaviors and weight status.

Making Childhood Obesity a Priority: A Qualitative Study of Healthcare Professionals' Perspectives on Facilitating Communication and Improving Treatment.

In Romania, one in four children has excess weight. Because childhood obesity is a sensitive topic, many healthcare professionals find it difficult to discuss children's excess weight with parents. This study aims to identify barriers and facilitators in childhood obesity-related communication, as perceived by healthcare professionals in Romania. As part of the STOP project, healthcare professionals (family physicians, pediatricians, and dieticians) who treat children with excess weight were invited to a telephone interview. The semi-structured questions were translated from a questionnaire previously used at the Swedish study site of the STOP project. Interviews were transcribed and then used for thematic analysis. Fifteen doctors and three dieticians (16 females and 2 males), with average 18.2 ± 10.1 years of experience, were interviewed. Four main themes were identified. Professionals reported that when children began experiencing obesity-related stigma or comorbidities, this became the tipping point of weight excess, where parents felt motivated to begin treatment. Barriers in communication were part of several layers of distrust, recognized as tension between professionals and caregivers due to conflicting beliefs about excess weight, as well as lack of trust in medical studies. Most respondents felt confident using models of good practice, consisting of a gentle approach and patient-centered care. Nonetheless, professionals noted systemic barriers due to a referral system and allocation of clinical time that hinder obesity treatment. They suggested that lack of specialized centers and inadequate education of healthcare professional conveys the system does not prioritize obesity treatment and prevention. The interviewed Romanian doctors and dieticians identified patient-centered care as key to treating children with obesity and building trust with their caregivers. However their efforts are hindered by healthcare system barriers, including the lack of specialized centers, training, and a referral system. The findings therefore suggest that, to improve childhood obesity prevention and treatment, systemic barriers should be addressed. Trial Registration: ClinicalTrials.gov, NCT03800823; 11 Jan 2019.

Assessing the quality of ReSPECT documentation using an accountability for reasonableness framework.

BACKGROUND: The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form, which supports the ReSPECT process, is designed to prompt clinicians to discuss wider emergency treatment options with patients and to structure the documentation of decision-making for greater transparency. METHODS: Following an accountability for reasonableness framework (AFR), we analysed 141 completed ReSPECT forms (versions 1.0 and 2.0), collected from six National Health Service (NHS) hospitals in England during the early adoption of ReSPECT. Structured through an evaluation tool developed for this study, the analysis assessed the extent to which the records reflected consistency, transparency, and ethical justification of decision-making. RESULTS: Recommendations relating to CPR were consistently recorded on all forms and were contextualised within other treatment recommendations in most forms. The level of detail provided about treatment recommendations varied widely and reasons for treatment recommendations were rarely documented. Patient capacity, patient priorities and preferences, and the involvement of patients/relatives in ReSPECT conversations were recorded in some, but not all, forms. Clinicians almost never documented their weighing of potential burdens and benefits of treatments on the ReSPECT forms. CONCLUSION: In most ReSPECT forms, CPR recommendations were captured alongside other treatment recommendations. However, ReSPECT form design and associated training should be modified to address inconsistencies in form completion. These modifications should emphasise the recording of patient values and preferences, assessment of patient capacity, and clinical reasoning processes, thereby putting patient/family involvement at the core of good clinical practice. Version 3.0 of ReSPECT responds to these issues.

General practitioners' experiences of emergency care and treatment planning in England: a focus group study.

BACKGROUND: Emergency 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. METHODS: We conducted five focus groups with GPs in areas being served by hospitals in England that have implemented ReSPECT. Participants 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. RESULTS: GPs 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. CONCLUSION: Conceptualising 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.