Many “do not resuscitate” decisions in England during pandemic ignored equality and human rights laws, says CQC
BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n754 (Published 18 March 2021) Cite this as: BMJ 2021;372:n754
Equality and human rights laws were flouted when “inappropriate” advance non-resuscitation decisions were taken during the covid-19 pandemic, the Care Quality Commission (CQC) has found in a government commissioned report.1
The Department of Health and Social Care for England asked the CQC to carry out a rapid review after allegations that blanket “do not attempt cardiopulmonary resuscitation” (DNACPR) decisions were imposed on some groups, such as people in care homes, and that some people with DNACPR decisions in their records were unaware of the fact.
Advance decisions not to attempt cardiopulmonary resuscitation should a person’s heart or breathing stop in the future should be made only after discussion with the person involved or the family if the patient lacks capacity, and they should be made on an individual basis, the CQC emphasised. But, amid fears early in the pandemic that hospitals could be overwhelmed with covid-19 patients, some care homes were issued with blanket DNACPR notices.
The CQC’s report said, “While we did not find there had been a national blanket approach to DNACPR, there was undoubtedly confusion at the outset of the pandemic and a sense that some providers felt under pressure to ensure DNACPR decisions were in place. This risks undermining public trust and confidence in the health and care system and demonstrates the need for better oversight of DNACPR decisions.”
It was “unacceptable for any DNACPR decisions to me made without proper conversations with the individual or appropriate representative, taking into account their wishes and needs,” the CQC added. Its interim report last November concluded that some care home residents were wrongly subjected to DNACPR decisions in the early stages of the pandemic, leading to potentially avoidable deaths.2
The final report found that the pressures of responding to covid-19, a lack of training, and a large amount of rapidly changing guidance about all aspects of providing care during the pandemic had contributed to the failings. “Inspectors 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,” it said.
Improved training
The CQC called for a ministerial oversight group to work with partners in health and social care, local government, and the voluntary sector to deliver on the report’s recommendations. These included better information, training, and support; a consistent national approach to advance care planning; and improved oversight and assurance.
“DNACPR decisions need to be recognised as part of wider conversations about advance care planning and end of life care, and these decisions need to be made in a safe way that protects people’s human rights,” said the report.
Most areas seen by the inspectors were not monitoring DNACPR decisions, and some patients were discharged from hospital with a DNACPR decision that they or their families were not aware of. The report acknowledged that, although the pandemic had brought the issue to the fore, it was not a new one and that “poor DNACPR decisions that put people’s human rights at risk have long been an issue in England.”
The charity Compassion in Dying, which issued its own report on DNACPR decisions to coincide with the CQC’s report, echoed the call for improved training, information, and support for healthcare professionals, a public health awareness campaign on “do not resuscitate” decisions, and a consistent national approach to record keeping and sharing.3
Julie Bass, chief executive of Turning Point, a national organisation supporting people with learning disabilities, said, “Families and care workers need to be empowered to call out prejudice. That’s why we back the CQC recommendations for improved oversight and reform.”
A spokesperson for the Department of Health and Social Care said, “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.”