CQC finds that some Do Not Attempt CPR orders in care homes during the pandemic may have been inappropriately put in place
The CQC’s initial findings from a report into the inappropriate use of DNACPR orders within care homes finds that those in place could have potentially caused avoidable deaths. Note that this report is in the process of being drafted and is on the basis of 40 submissions received from the public which is a small proportion but which could signal a wider problem. CQC is also imploring services to review the DNACPRs that are currently in place within care homes in order to assure themselves of the accuracy of those that have been put in place.
It is important to understand what the purpose of a DNACPR is. CPR is the most extreme version of resuscitation and involves attempts to restart the heart or breathing and restore the circulation of the person to whom it is administered. It is invasive, it can have a low success rate depending on the patient, and can involve the breaking of bones in the ribcage and internal damage to organs which may not be clinically advisable in residents which are more at risk owing to their risk profiles- for example their medical conditions or frailty. Whilst CPR can indeed save a life the existence of a DNACPR order does not prevent those being cared for by alternative methods of life saving being actioned- any other method which does not involve performing CPR. That being said a DNACPR will only be installed in the most extreme cases after deliberation and consultation with a clinician and the wishes of the individual with capacity and if not in conjunction with those legally entitled to participate in decision making in respect of that individual. It should not be a measure which is applied in a blanket fashion which is a concern which was raised during the pandemic. This was one of the reasons why CQC have embarked upon this report to ascertain what the accurate picture is in care homes.
Quite apart from a DNACPR, which applies in very particular scenarios, care homes should also have in place an end of life care plan for those residents who are approaching the end of their life or whom have expressed an interest in advance planning for the end of their life. This is irrespective of whether the resident is deemed to have capacity or not and attempts should be made with relevant clinicians and the support of those around the individual without capacity in order to obtain the wishes of the resident. This is of course a difficult discussion to contemplate but is one which it is important to have nevertheless to maintain the dignity of an individual and fulfil their wishes as far as is legally possible.
It is questionable whether a review of just 40 records by the CQC can constitute a review which is reflective of the care homes’ in England’s use of DNACPR orders during the pandemic. But it is certainly an area which requires in-depth scrutiny by providers in order to ensure that DNACPR orders are properly considered prior to being put into place. This may be an area which piques the CQC’s interest more in the coming months in order to ensure that DNACPRs are indeed fit for purpose and providers should be able to evidence how such decisions have been reached on a case-by-case basis.
For further information on the sensitive issue of DNAR my colleague Paul Ridout wrote further on this matter here.
Should there be a finding that a DNACPR has been installed without proper consultation of someone representing the interests of an individual, this could constitute a breach of the Article 8 rights (respect for private and family life). This has been tested in the courts previously where a finding was made in respect of an NHS Trust and a declaration was ordered against it for a failure to properly communicate how a DNACPR had been reached but no financial award was given. This is however a point which I am sure providers will want to ensure that it is properly taken and the CQC is likely to take issue with departures from the best practice position of properly documenting and being able to explain how DNACPR decisions have been reached.
Providers should be mindful of ensuring that the DNACPRs that are in place are properly documented and proper involvement from the relevant parties has been sought out and recorded. A failure to have such assurances could see Providers being accused of breaches of CQC registration in respect of a whole host of different regulations, from person-centred care to dignity and respect and safe care and treatment to name a few. Breaches of regulation are likely to lead to increased scrutiny from the regulator and at the most extreme cancellation of registration. The CQC is likely to take issue with providers which cannot demonstrate properly considered DNACPRs and will take enforcement action against those providers who are unable to demonstrate that the proper processes have been taken in reaching an advanced decision regarding CPR. The CQC’s refocusing on risk and acting on information provided to it by the public may see an increased focus on the area of DNACPRs and the ability of providers to prove their compliance with best practice in this area is likely to be a new key area upon which CQC will focus.