Concern over hundreds of do not resuscitate decisions made without discussion – watchdog

Royal Alexandra Hospital, Paisley
PA Wire
18 March 2021

Some 500 cases where do not attempt to resuscitate decisions were made during the coronavirus pandemic in a breach of human rights, the care regulator has found.

The Care Quality Commission (CQC) has called for ministerial involvement to tackle the “worrying variation” in people’s experiences of do not attempt cardiopulmonary resuscitation (DNACPR).

Some families were not properly involved and others unaware that decisions had been made, it said.

It found that a combination of “unprecedented pressure” on providers and “rapidly developing guidance” may have led to situations where DNACPR decisions were incorrectly conflated with other clinical assessments.

There were examples of good practice but the regulator also found a “worrying picture” of poor involvement of people using services, poor record keeping, and a lack of oversight and scrutiny of the decisions being made.

But it noted that the issues raised - such as the need forproper, consistent processes around timely conversations about people’scare - pre-dated the pandemic.

The CQC was asked by the Department of Health and Social Care toconduct a rapid review of how DNACPR decisions were used at the start ofthe coronavirus pandemic.

It followed concerns that decisions were being made without theinvolvement of patients or relatives, and that they were being appliedin a blanket way to particular groups, for example people with learningdisabilities.

The CQC produced an interim report in December which found thatdoctors may have made blanket decisions without the input of patients ortheir families during the first wave of the pandemic.

The latest report includes evidence from seven ClinicalCommissioning Groups (CCGs), responses from adult social care providers,a public survey and voluntary sector organisations.

Some 2,048 adult social care providers responded to the CQC, andsaid that 508 DNACPR decisions made since March 17 2020 had not beenagreed in discussion with the person, their relative or carer.

Around a third (180) were still in place in December.

And, while responsibility for making DNACPR decisions does notlargely rest with adult social care providers, 119 providers said peoplein their care had been subject to blanket DNACPR decisions since March2020.

The CQC said the figures raised concerns about whether theproviders making these decisions were at risk of breaching the EqualityAct 2010.

Most providers of adult social care, and primary and secondary care, said they were not aware of inappropriate DNACPR decisions.

But other stakeholders, service users, families and carers said blanket DNACPR decisions had been proposed locally.

The regulator heard evidence that these decisions were “quickly challenged and retracted”.

One person told the CQC: “I only found out about the (DNACPR)when they were discharged from hospital; no-one had mentioned it to mebefore nor to the person concerned. It was a tremendous shock.”

Another said: “I felt pressured to accept the decision of thedoctors as they illustrated a terrible picture (i.e. immense sufferingof the person) if I did not.”

It is calling for a Ministerial Oversight Group to work withhealth and care providers, local government and the voluntary sector todeliver improvements.

It wants to see a consistent national approach to advance careplanning, with staff training, accessible information for families andrecords of conversations and decisions agreed.

Rosie Benneyworth, chief inspector of Primary Medical Servicesand Integrated Care at the CQC, said: “It is vital we get this right andensure better end-of-life care as a whole health and social caresystem, with health and social care providers, local government and thevoluntary sector working together.

“Covid-19 has brought this to the fore but these are not new issues.”

Age UK said the approach to advance care planning needed a”complete overhaul”, with strengthened support for professionals andfamilies with concerns.

It was also calling for a review so that any “hasty, ill-informed decisions” could be removed from older people’s records.

Charity director Caroline Abrahams said: “The treatment we wouldlike or not if we become desperately ill or if our heart stops beatingis one of the most important decisions any of us will ever make, so it’sextremely disturbing that this report effectively stands up the notionthat some older people’s rights to choose were ridden roughshod overduring the pandemic.

“It is doubly concerning that the CQC says these problems werenot unique to the pandemic but were happening to a degree before it evenarrived.”

Dan Scorer, head of policy at the learning disability charityMencap, said: “CQC’s important review into use of DNACPRs during thepandemic highlights the urgent need for better staff training andsupport to ensure the right of people with a learning disability, andtheir families, to be involved in decisions about care and treatment isupheld.

“It is unacceptable that assumptions are made about people’squality of life or their wishes in relation to treatment. They deserveand have a right to so much better.”

An NHS spokesman said: “The NHS has repeatedly instructed localclinicians and services that the blanket DNA(CPR) decisions would beunacceptable - including on three separate occasions in less than amonth at the start of the pandemic, and again last week - and thataccess to treatment and care for people should be and is made on anindividual basis in consultation with family and carers.”

A DHSC spokesperson said: “It is totally unacceptable for ‘Do NotAttempt CPR’ orders to be applied in any kind of blanket fashion - thishas never been policy and we have taken decisive action to prevent itfrom happening, working closely with the health and care sector to makethis clear and asking the CQC to undertake this review.

“We support the recommendations in this report and we aredetermined to ensure everyone receives the compassionate care theydeserve in all settings.”

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