Improper ‘do not resuscitate’ orders potentially led to avoidable deaths, says regulator

The Care Quality Commission (CQC) says “inappropriate” decisions taken around the application of some orders were due to pressure on care providers during the early stages of the pandemic.

Wrongly applied do-not-resuscitate orders given to some residents in English care homes could have resulted in potentially avoidable deaths during the early phase of the pandemic, an interim report by the CQC has found.

Announced in October, the CQC review was prompted by concerns about potential misapplication of do not attempt cardiopulmonary resuscitation (DNACPR) notices in care homes during the early stages of the pandemic.

DNACPR notices are commonly found within end-of-life care environments and can be made by a medical practitioner such as a GP or suitably qualified nurse in accordance with the individual involved. They are often found in advance care plans as CPR saves very few lives outside of a hospital setting and often causes substantial damage to those who do survive.

However, the CQC says that it is "unacceptable" for DNACPR decisions to be applied to "groups of people of any description” and that they should only be implemented “with clear involvement of the individual, or an appropriate representative, and a clear understanding of what they would like to happen.”

The report identified 40 submissions from the period March to September where relatives or even some individuals did not know that a DNACPR order had been placed until late-stage illnesses had developed, compared to nine for the previous six-month period.

The regulator warned that whilst there was no evidence that any blanket approach was currently in effect, individual DNACPR notices may still be in place.

Rosie Benneyworth, Chief Inspector of Primary Medical Services and Integrated Care at the Care Quality Commission, said there was “very real concern” that decisions around DNACPR notices had been made that “not only overlooked the wishes of the people they affected, but may have been made without their knowledge or consent.”

The report found that this practice was provoked due to fears around overwhelming NHS hospitals with additional patients.

The CQC pointed to “unprecedented pressure” on care providers in the spring, as well as “confusion” over the implementation of guidance around the decision process of DNACPR notices as reasons for the misapplications of some orders.

The full report is expected to be published in early 2021 and will expand its focus to include the experiences of older people within the community, as well as people with a learning disability or autism.

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