In March 2021, CQC published a report titled, “Protect, respect, connect – decisions about living and dying well during COVID-19: CQC’s review of ‘do not attempt cardiopulmonary resuscitation’ decisions during the COVID-19 pandemic”. The report was published following CQC’s review of ‘do not attempt cardiopulmonary resuscitation’ (“DNACPR”) decisions during the COVID-19 pandemic. A copy of the report can be accessed here.
As providers know, a DNACPR decision is an instruction to healthcare professionals involved in a person’s care not to attempt cardiopulmonary resuscitation (“CPR”). DNACPR decisions are intended to be a positive intervention and as stated in CQC’s report, “designed to protect people from unnecessary suffering by receiving CPR that they don’t want, that won’t work or where the harm outweighs the benefits.” Every decision about whether or not a person should receive CPR must be made after careful assessment of each individual’s situation. This should be done in consultation with the person (and / or their representative depending on their individual circumstances).
From the beginning of the COVID-19 pandemic, there were concerns that DNACPR decisions were being made without involving people (or their families or carers) and were being applied to groups of people, rather than taking each person’s individual circumstances into account. There were particular concerns that this was affecting people with a learning disability and older people. CQC’s review looked at how DNACPR decisions were made in the context of advance care planning, across all types of health and care sectors (including care homes, primary care and hospitals).
CQC’s findings from the review were that, going forwards, there needs to be a focus on three key areas:
- Information, training and support.
- A consistent national approach to advance care planning.
- Improved oversight and assurance.
Issues identified by CQC in relation to DNACPR decisions
CQC found that whilst, “some people felt they had been involved in the decision-making process, as part of a holistic conversation about their care… others felt that conversations around whether they would want to receive cardiopulmonary resuscitation (CPR) came out of the blue and that they were not given the time or information to fully understand what was happening or even what a DNACPR was. In some cases, people were not always aware that a DNACPR decision was in place.” Out of 2,048 adult social care providers who responded to CQC’s information request for information regarding DNACPR decisions, it was found that 508 out of 9,679 of DNACPR decisions put in place since 17 March 2020 had not been agreed in discussion with the person, their relative or carer.
CQC attributed the training and support that staff received, as a key factor in whether advance care planning conversations were held in a person-centred way and protected their human rights. CQC found that there were many types of advance care planning in use (including a variety of acronyms) and concluded that there needs to be a consistent national approach to advance care planning and DNACPR decisions. CQC also found that there needed to be a consistent use of accessible language, communication and guidance to enable shared understanding and information sharing among commissioners, providers and the public.
CQC also found that there was a need for improved oversight of DNACPR decisions to ensure that people’s rights are protected. The report stated that, “Without proper oversight, systems could not be sure that clinicians, professionals and workers were being supported to keep their professional practice and knowledge up to date in line with best practice, and to work within this. This is an area that needs rapid evaluation given the issues we have identified with staff knowledge and understanding. It is also pivotal to the development of end of life strategies at a system-wide level.”
Human rights implications
CQC heard evidence that in some cases, ‘blanket’ DNACPR decisions had been made. Blanket DNACPR decisions, failing to discuss with people whether or not they want CPR to be attempted and people not understanding when a DNACPR decision is in place are all potential human rights issues. They are also potentially discriminatory and unlawful under the Equality Act 2010.
Measures for providers to implement
CQC’s report stated that CQC will, “ensure a continued focus on DNACPR decisions through… monitoring, assessment and inspection of all health and adult social care providers”. Therefore, now that we have come out of the third national lockdown and restrictions have been eased, it would be a good time for providers to ensure that they have the following measures in place:
- Suitable staff training in relation to advance care planning and end of life care, covering the topic of DNAR decision making. Staff training should help to enable DNACPR decision making conversations to take place in a person-centred way and to reduce the risk of inappropriate decision making.
- Clear communication – with the individuals to whom the DNACPR decision relates to and / or their families and representatives (depending on the person’s capacity and wishes).
- Robust record keeping – ensure there are comprehensive records of conversations with and decisions agreed with, people, their families and/or representatives. To assist with this providers should ensure that there is consistency in records by using the same advance care planning forms, same acronyms and accessible language.
- Governance of DNACPR decisions – providers should ensure that there is sufficient oversight of DNACPR decisions relating to service users in their service. Providers may want to consider including reviewing DNACPR decisions as part of their service’s monthly audits. This will also help to demonstrate to CQC that this is a “Well-led” service.
Conclusion
Advanced care planning is a difficult and sensitive area. Reaching and making DNACPR decisions is most certainly not a routine form filling exercise and caution should be exercised when DNACPR decision making conversations take place with service users.
Any deaths which are a result of a failure to act are just as unlawful as death caused by a deliberate action. If either the failure or the act are not sanctioned by the law that may be categorised as neglectful or even criminal. Therefore, it is of the utmost importance that DNACPR decisions are properly completed with full knowledge of relevant information and that the consent remains valid when the decision is to be made.
Providers should also be mindful that CQC will be monitoring DNACPR decisions during future inspections. It is therefore a good idea to ensure that the measures set out in bullet points above are either implemented or if they are already in place, reviewed and strengthened further.
If providers need any advice or assistance in relation to issues arising from DNACPR decisions or issues arising from CQC inspections, our specialist solicitors can help. Please contact Ridouts Professional Services Ltd using the email address info@ridout-law.com or by calling 0207 317 0340.
