The use of do not attempt resuscitation orders will be reviewed by health regulators after it emerged some care homes have blanket policies in place covering residents.
Some doctors told care home managers to apply the orders to many residents at once at the start of the coronavirus pandemic in March without proper consultation.
This meant residents were unlikely to be taken to hospital for life-saving care, and it is now feared widespread orders could still be in place as the virus spreads again.
Now, the Care Quality Commission, the health regular for England, will review the use of the ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) orders.
The orders mean a patient will not get CPR if their heart stops, and are supposed to be agreed between a doctor and the person affected or their next of kin.
It is so far unclear why the blanket orders were encouraged, but there are thought to have been fears over having to have a large number of emotional conversations with patients and relatives if all of them were contacted about the notices in advance.
The Care Quality Commission will review the use of the ‘do not attempt cardiopulmonary resuscitation’ orders. Pictured: A stock image of a man with a ventilator in intensive care
The review was announced by Lord Bethell in the House of Lords on October 1, and the CQC has since been developing its scope and methodology before starting it.
Compassion In Dying has been calling for an inquiry into the use of DNACPR and Do Not Attempt Resuscitation (DNAR) orders during the pandemic.
Wife found husband’s DNR order when she looked at a nursing folder left on her sofa
A wife found out her husband had a do not resuscitate order by chance when she looked in a community nursing folder left on her sofa.
Sonya Brown’s husband Alan had been diagnosed with lung cancer in October 2019 and went into hospital in late March 2020 with suspected Covid-19.
Tests later came back negative and he was discharged home after several days, but he then died on April 3.
Sonya Brown found out her husband had a do not resuscitate order by chance when she looked in a community nursing folder left on her sofa
Mrs Brown, 51, of Lanarkshire, told how she ‘overwhelmed’ by the discovery of the notice in his file.
She said: ‘Inside the folder I found a document which said ‘do not resuscitate’. It was dated the day Alan went into the hospital.
‘I was just overwhelmed when I saw it. At no point did someone explain that his disease was progressing and this was normal.
Mrs Brown, 51, of Lanarkshire, with her husband Alan Brown, who died on April 4
‘We felt completely adrift. I felt such guilt about the DNR. If I had tried to lift it would he have lived?
‘I now understand the rationale for one being in place, but what I don’t understand is why no one thought to phone me and talk to me about it, particularly when I couldn’t be with him in hospital because of lockdown.’
The charity said that it has heard several reports since March about such orders being made for patients across a range of healthcare settings in a blanket fashion.
Usha Grieve, director of partnerships and information at Compassion in Dying, said yesterday: ‘As we face a second wave of coronavirus, we must recognise and learn from the mistakes of the first and we welcome the CQC’s announcement of a rapid review into the use of DNRs.
‘We have called for an inquiry into these issues for some time and look forward to working with the CQC to share our insights, having received several reports of poor and unlawful practice related to DNRs before and during the pandemic.
‘Coronavirus has highlighted and exacerbated ongoing problems with decision-making and communication around DNRs, which have proliferated under a lack of clear, national guidance.
‘This has had devastating effects on patients and families right across the spectrum – from DNRs being issued in a blanket way, to decisions not being properly communicated or explained to patients or families, to people who want to protect themselves from potentially harmful or futile CPR feeling ignored.’
The charity also revealed polling which found more than half of people do not understand DNR or DNACPR orders.
A survey by YouGov found most people did not know that a DNR decision is made if a clinician thinks that attempting CPR will do more harm than good (51 per cent); that a DNR decision must be explained to a patient and/or their family (54 per cent); or that a patient will still continue to receive other care if a DNR decision is made (51 per cent).
The charity, which helps people prepare for the end of life including how to talk about it, plan for it and record their wishes, regularly receives calls to its free, nurse-led information line on the subject of CPR and DNRs, and said queries have on this almost doubled since August.
Dr Rosie Benneyworth, chief inspector of primary medical services and integrated care at the Care Quality Commission, said yesterday: ‘We welcome this commission from Department of Health and Social Care and are taking it forward at pace.
‘This builds on the concerns we reported earlier in the year and we are pleased that they are being given closer attention.
‘Health and social care providers have faced extraordinary pressures this year. Both staff, and people using services and their loved ones, have at times raised concerns with us about care.
‘It is vital that we take this opportunity to learn from what has happened – challenging poor care and sharing the ways that providers have put people’s needs at the heart of their care so that others can learn from them.’
She added: ‘Along with partners we have been clear that it is unacceptable for advance care plans, with or without Do Not Attempt Resuscitation form completion, to be applied to groups of people of any description.
‘These decisions must continue to be made on an individual basis according to need. Through this review we will look to identify and share best practice in this complex area, as well as identifying where decisions may not have been patient-centred and ensuring mistakes are not repeated.’
Dr Rosie Benneyworth, chief inspector of primary medical services and integrated care at the Care Quality Commission, said social care providers have faced ‘extraordinary pressures’
Dan Scorer, head of policy at the learning disability charity Mencap, said: ‘The 1.5 million people with a learning disability across the UK have a right to equal access to healthcare just like anyone else.
What are Do Not Resuscitate orders and who can invoke them?
What is a Do Not Resuscitate order?
A DNR order is a legal order which tells a medical team not to perform CPR on a patient. However, this does not affect other medical treatments.
Who can invoke a DNR?
The British Medical Association and the Royal College of Nursing say that DNR orders should only be issued after discussions have been held with patients or their family.
A patient may decline resuscitation if they have capacity as defined under the Mental Health Act 2005.
If patients want to record this in a legally binding document they should plan to make an ‘advance decision to refuse treatment’ (ADRT), but it is often best to have it recorded on a CPR decision form as well, so that healthcare professionals will recognise it easily. Or they can simply ask your healthcare professionals to record your decision on a CPR decision form.
When would it not be appropriate to attempt resuscitation?
Not everyone wants to receive attempted CPR, so it is important to respect people’s wishes and to make sure that they are offered a chance to make choices that are right for them.
When someone’s heart and breathing stop because they are dying from an advanced and irreversible condition, CPR will subject them to a vigorous physical intervention that deprives them of a dignified death. For some people this may prolong the process of dying and, in doing so, prolong or increase suffering.
When there is a chance CPR may bring someone back from cardiac arrest to a length and quality of life that they would want, they should be offered:
- The chance to be given clear and accurate information about their condition and the likely risks and benefits from CPR if they should suffer cardiac arrest;
- The chance to express their beliefs and wishes and to make a shared decision with their health professionals on whether or not they should receive attempted CPR if they should suffer cardiac arrest.
‘Yet the potentially unlawful use of ‘Do Not Resuscitate’ (DNR) notices for fit and healthy people with a learning disability during the first wave of the Covid-19 pandemic was discriminatory and quite literally put their lives in danger.
‘While we welcome the review into the use of these notices in care homes – including whether some are still in place illegally – this must go further.
‘The review needs to examine DNR policy and practice across health and care settings, for disabled people of all ages, and set out changes needed to protect people’s rights so that unacceptable practice cannot be repeated.’
On September 21, a parliamentary committee raised concerns over the extent of DNACPR notices in care homes during the pandemic, warning that their blanket use would be unlawful.
It urged the Department of Health to take a ‘more proportionate approach’ when it came to issuing guidance on visiting care homes, and called on ministers to ensure homes were not imposing blanket bans on visitors.
The Joint Committee on Human Rights said at the time: ‘Restrictions on visiting rights must only be implemented on the basis of an individualised risk assessment and such risk assessment must take into account the risks to the person’s emotional wellbeing and mental health of not having visits.’
The committee also said ministers should organise ‘a quick, interim review’ into deaths from coronavirus to ensure key lessons were learned in advance of any second peak in the autumn and winter.
That came after the Government issued new guidance on the orders in July after a woman threatened legal action over concerns that ill coronavirus patients’ human rights in care homes and hospitals were being ignored.
Kate Masters had threatened to sue the Government over its failure to provide consistent advice on the notices during the pandemic.
She previously said the decision-making process around the orders had ‘become opaque, inconsistent and deficient’ amid reports of poor practice, including elderly patients apparently being pressured into signing the forms, during the crisis.
Ms Masters’s late father David Tracey had brought a successful judicial review establishing a violation of his late wife Janet’s human rights while she was treated in Addenbrooke’s Hospital, in Cambridge, after a fatal car crash in 2011.
In June 2014, the Court of Appeal ruled that the human rights of 63-year-old care home manager Mrs Tracey, who had terminal lung cancer, were violated when an order was placed on her medical notes without discussing it with her first.
The case established there was a legal duty to consult with and inform patients if an order was placed on their records except in very narrow circumstances.
On April 7, health leaders in England wrote to medics across the country reminding them that ‘blanket policies are inappropriate’.
Professor Stephen Powis, medical director for the NHS in England, and Ruth May, chief nursing officer for England, wrote: ‘Blanket policies are inappropriate, whether due to medical condition, disability, or age.
‘This is particularly important in regard to ‘Do not attempt cardiopulmonary resuscitation’ orders, which should only ever be made on an individual basis and in consultation with the individual or their family.’
That came after the CQC told all healthcare providers on March 30 that it was ‘unacceptable for advance care plans, with or without DNAR form completion, to be applied to groups of people of any description’.
In a joint statement, it said: ‘The importance of having a personalised care plan in place, especially for older people, people who are frail or have other serious conditions has never been more important than it is now during the Covid 19 Pandemic.
‘Where a person has capacity, as defined by the Mental Capacity Act, this advance care plan should always be discussed with them directly.
‘Where a person lacks the capacity to engage with this process then it is reasonable to produce such a plan following best interest guidelines with the involvement of family members or other appropriate individuals.’
That statement, issued jointly with the British Medical Association, Care Provider Alliance and Royal College of General Practitioners, added: ‘It is unacceptable for advance care plans, with or without DNAR form completion to be applied to groups of people of any description.
‘These decisions must continue to be made on an individual basis according to need.’