There is evidence that ‘do not resuscitate’ orders were used in an ‘unacceptable and inappropriate’ way at the start of the Covid-19 pandemic, a review by the Care Quality Commission (CQC) has found.
The regulator, prompted by concerns the orders were being used in a blanket fashion, investigated existing evidence and interviewed 47 stakeholders, including representatives of people who use services.
While it found ‘no evidence’ of blanket approaches to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions being taken currently, the CQC heard that early in the pandemic, individuals and their loved ones ‘received DNACPR decisions which were not based on their wishes and needs, and without their knowledge and consent’.
Some interviewees said care providers and staff had raised the issue of blanket DNACPR orders being used, with some GPs placing them on care homes, according to the report.
Inappropriate use of DNACPRs
All respondents, including those in the voluntary sector, said they had either ‘actual or anecdotal evidence’ the orders were being used inappropriately between March and April 2020, it added.
The CQC said: ‘One told us the doctor on call had advised care home staff that if the older people in their care contracted Covid-19, they would have a DNACPR put in place.
The regulator said inappropriate use of DNACPR ‘could be unlawful’ under the Equality Act 2010, if the decision-making is based on the protected characteristics of age and disability, and that decisions must instead be made on an individual basis according to need.
An increase in complaints
The CQC also reported an increase in the online feedback it received relating to DNACPR use between March and September 2020, with 40 submissions compared to nine in the previous six months.
Most concerned orders being placed without consultation with an individual or their family, it added, and there were ‘some examples where DNACPR orders were placed on numerous people routinely’.
The online feedback showed some people were left unaware they had a DNACPR order placed on them, while other responses raised questions over ‘informed consent’, due to reasons such as deafness or patients not speaking English, CQC said.
‘Confusion and miscommunication’
The report concluded that there was ‘confusion and miscommunication’ about the application of DNACPRs at the start of the pandemic, and a sense of providers being ‘overwhelmed’.
It found that clinical pathways, guidance and protocols put in place during the pandemic may have led to older and disabled people not being given access to acute care, including those in care homes who may have been denied access to a hospital against their wishes.
Interviewees also said some families ‘had felt unable to fight the issue, or were not aware it was inappropriate, and there wasn’t enough access to advocates to fight on their behalf’.
People with physical and learning disabilities, and those from ethnic minority backgrounds ‘felt their lives were less important as a result’, the CQC heard.
Despite the review not finding evidence of blanket DNACPR orders being applied currently, some interviewees said they felt ‘severe anxiety and worry’ that these practices are continuing or could be seen again in future.
The CQC said it will publish a full national report in February 2021, which sets out key trends, outlines any known changes to the use of DNACPR in response to the pandemic, and describes good practice.
‘Blanket DNACPRs are unacceptable’
Rosie Benneyworth, CQC chief Inspector of primary medical services and integrated care, said: ‘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.
‘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.’
Dr Bennyworth added that the findings have highlighted that inequalities in the care people receive risk being ‘magnified’ by the impact of the coronavirus pandemic.
‘We have also highlighted the fact that it is possible in some cases that inappropriate DNACPRs remain in place – and made it clear that all care providers have a responsibility to assure themselves that any DNACPR decisions have been made appropriately, in discussion with the person and in line with legal requirements,’ she said.
