Pressures and guidance may have led to incorrect care decisions

Incorrect decisions on the use of do not attempt cardiopulmonary resuscitation (DNACPR) may have occurred due to a combination of ‘unprecedented pressure’ on care providers and developing guidance.

The Care Quality Commission (CQC) has published an interim report from its review, commissioned by the Department of Health and Social Care, of DNACPR decisions taken during the pandemic.

In April, the CQC, British Medical Association, Care Provider Alliance and Royal College of General Practitioners, issued a statement telling providers it was unacceptable for advance care plans with or without do not attempt resuscitation form completion to be applied to groups of people.

Early findings show that, as the pandemic progressed, there were concerns that DNACPRs were being used to influence decisions about wider care and treatment.

The regulator received 40 submissions between March and September, compared with nine during the previous six months, the majority of which raised concerns about orders that had been put in place without consulting with the person or their family.

One example noted how care staff were asked to take observations they were not trained for, and all residents had a DNACPR in place because doctors refused to visit the home following the deaths of two residents from Covid.

Only the most senior clinician responsible for a person’s care, a consultant, GP or experienced and competent nurse, can make a DNACPR decision.

Some reports said people and their families were unaware they had a DNACPR order, often not finding out until the person became very unwell.

CQC pointed out NICE guidance issued in March intended to help clinicians assess frailty may have been misinterpreted and needed to be revised five days later.

These early findings have provided the CQC with a base to carry out fieldwork in seven clinical commissioning groups. A final report is due to be published early 2021.

‘It is unacceptable for clinical decisions – decisions which could dictate whether someone’s loved one gets the right care when they need it most – to be applied in a blanket approach to any group of people,’ said Rosie Benneyworth, chief inspector of primary medical services and integrated care at the CQC.

‘Sadly, in the experiences that people have generously shared with us there is very real concern that decisions were made which not only overlooked the wishes of the people they affected, but may have been made without their knowledge or consent.’

Benneyworth added it is possible in some cases that inappropriate DNACPRs remain in place, and all care providers have a responsibility to assure any DNACPR decisions have been made appropriately, in discussion with the person and in line with legal requirements.