Blanket ‘do not resuscitate’ orders enforced in care homes during first wave

There was a “worrying variation” in people’s experiences of do not attempt cardiopulmonary resuscitation (DNACPR) decisions during the first wave of the pandemic, including instances of blanket imposition of orders on residents, a new report from the Care Quality Commission (CQC) has found.

In its review of the initial response to the onset of the pandemic in March 2020, the CQC confirmed it had received feedback from stakeholders and service users and their families that ‘blanket’ DNACPR decisions had been proposed at a local level and 119 adult social care providers felt they had been subjected to blanket DNACPR decisions since the start 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 within ‘advance care plans’ (ACP), as medical experts suggest that CPR saves very few lives outside of a hospital setting and often causes substantial damage to those who do survive.

The report highlighted serious concerns about instances of human rights breaches in certain cases, including an example in which a GP placed DNACPR orders onto 80 care home residents without permission from the individuals or their families.

The report found the number of DNACPRs implemented within care homes in England at the beginning of the pandemic had risen by almost 60% to 26,555.

An interim report from the CQC published in December 2020 found that the practice was provoked due to fears around overwhelming the NHS hospitals with additional patients.

The CQC pointed to “unprecedented pressure” on care providers throughout Spring 2020, 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 newly published report found a combination of poor involvement of service users within DNACPR decisions, as well as generally poor record keeping, and a lack of oversight and scrutiny contributed to wrongly applied orders.

The report acknowledged the unique pressures and situations that the pandemic presented to care homes within a very short time frame, including on the time that staff had to hold meaningful conversations on DNACPR decisions.

A lack of training and a large amount of rapidly changing guidance about all aspects of providing care during the pandemic also presented significant barriers, the report found.

Rosie Benneyworth, Chief Inspector of Primary Medical Services and Integrated Care at the Care Quality Commission said that the pandemic had exacerbated long-standing issues from before the onset of the crisis.

“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.”