CQC's Human Rights Concerns Over Blanket Do Not Resuscitate Decisions

Peter Russell

March 18, 2021

The Care Quality Commission (CQC) has expressed "serious concerns" that individuals' human rights may have been breached in more than 500 cases where do not attempt cardiopulmonary resuscitation (DNACPR) decisions were made during the COVID-19 pandemic.

The care quality watchdog for England said despite some examples of good practice, it heard reports from people who were not properly involved in decisions or were unaware that an important decision about care had been made.

Since March 2020, some 508 DNACPR decisions had not been agreed with the person involved or their families or carers, the report found.

"As a result, people were potentially being denied the opportunity to discuss their DNACPR decisions, advance care plans, and end of life care needs and wishes," the report said, and as a result "This presented a risk of inappropriate decision making and a risk of unsafe care or treatment."

Pandemic Pressures

The report acknowledged that the pandemic had placed health and care services under unprecedented pressure, which had reduced the time staff had to hold meaningful conversations.

Figures supplied to the CQC by adult social care providers suggested that the total percentage of DNACPRs put in place in care homes increased from 28% on March 16, 2020 to 36% for the period March 17 to December 2020.

The increase was even larger for nursing homes, which registered an increase from 74% to 92% during the same period.

The CQC said that early in the pandemic it had acted quickly to remind providers that it was unacceptable to apply decisions to groups of people rather than take into account each person's individual circumstances.

The CQC's rapid review, Protect, respect, connect – decisions about living and dying well during COVID-19,  described a "worrying picture of poor involvement, poor record keeping, and a lack of oversight and scrutiny of the decisions being made".

Call for Ministerial Oversight

Among its recommendations was a call to establish a Ministerial Oversight Group – working with partners in health and social care, local government, and the voluntary sector – to take responsibility for delivering improvements.

Rosie Benneyworth, chief inspector of primary medical services and integrated care at the CQC, said: "Personalised and compassionate advance care planning, including DNACPR decisions, is a vital part of good quality care. Done properly, it can offer reassurance and comfort for people and their loves ones – before and during difficult times.

"It is vital we get this right and ensure better end of life care as a whole health and social care system, with health and social care providers, local government and the voluntary sector working together.

"COVID-19 has brought this to the fore but these are not new issues. While this rapid review was not asked to make judgments on how decisions might have impacted individual cases, we have to take this opportunity to address these problems. We need to make sure that people have the opportunity to discuss their wishes about care and treatment in a compassionate and person-centred way."
 

Reaction to the Review

A spokesperson for the Department of Health and Social Care commented: "It is totally unacceptable for 'Do Not Attempt CPR' orders to be applied in any kind of blanket fashion – this has never been policy and we have taken decisive action to prevent it from happening, working closely with the health and care sector to make this clear and asking the CQC to undertake this review.

"We support the recommendations in this report and we are determined to ensure everyone receives the compassionate care they deserve in all settings."

The Royal College of Physicians said it fully supported the CQC's recommendations. Its President, Prof Andrew Goddard, said: "It is terribly concerning to hear of cases in which patients and their families/carers have not been fully involved or had negative experiences when discussing DNACPR.

"We know how difficult these conversations can be, which is why we recently updated our guidance for clinicians on how to approach conversations regarding end of life care and treatment."

Prof Martin Marshall, chair of the Royal College of GPs, said: "The College has been clear that any decision to complete an advance care directive or Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order must involve the patient and those important to the person – and made in a sensitive, fair and equitable way, carefully considering their individual circumstances and needs."

Carolyn Doyle, professional lead for community and end of life care for the Royal College of Nursing said: "There must never be blanket use of do not attempt cardiopulmonary resuscitation (DNACPR) decisions under any circumstances.

"End of life care must always be delivered with the utmost compassion and designed as part of the personalised care plan to suit each patient.

"Early communication with them and their family about resuscitation must be a key part of this process."

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