Evidence of "do not resuscitate" orders taken without consent

The Care Quality Commission (CQC) has published an interim report from its review into the application of do not attempt cardiopulmonary resuscitation (DNACPR) decisions during the COVID-19 pandemic. Early finds show that doctors may have made decisions about NACPR orders without consent at the beginning of the pandemic.

It found that a combination of unprecedented pressure on care providers and other issues may have led to decisions concerning DNACPR being incorrectly conflated with other clinical assessments around critical care.

As one example of the pressure and confusion at the time, CQC noted that guidance intended to help clinicians assess frailty as part of a wider, holistic assessment around the appropriateness of critical care may have been interpreted as the sole basis for clinical decisions in some instances.

In this case, the misinterpretation was quickly acknowledged, and revised guidance was issued five days later to make it clear that this was not an appropriate use of the tool.

DNACPR decisions and advance care plans should only ever take place with clear involvement of the individual, or an appropriate representative, and a clear understanding of what they would like to happen.

People who use services and groups that represent them told CQC that early in the pandemic they or their loved ones received DNACPR decisions which were not based on their wishes and needs, and without their knowledge and consent.

It is unacceptable for decisions to be applied to groups of people of any description.

However, differing views remain as to whether people are now receiving appropriate, person-centred care and support around this issue and CQC’s review continues. CQC’s review into the use of DNACPR is now undertaking rapid fieldwork in seven Clinical Commissioning Groups (CCGs) to better understand how DNACPRs have been used since the start of the pandemic and what good practice looks like. Further consideration is needed and the next stage of this work will be vital in identifying what local systems need to do so they can protect against possible future errors.

Rosie Benneyworth, Chief Inspector of Primary Medical Services and Integrated Care at the Care Quality Commission 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.

“As we warned in our recent State of Care report, these findings highlight that inequalities in the care people receive risk being magnified by the impact of the coronavirus pandemic. As this is such an important and sensitive issue, we have worked quickly to share these interim findings and we will continue this work so that we build on the evidence already shared and can make recommendations for the future. It is vital that we look at what happened on the ground, continue to speak to people using services and people working in them, so that we can make sure that the health and care system learns the crucial lessons it needs to from this difficult time.

“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.”

These interim findings have provided a base for the fieldwork currently underway in seven CCGs across the country. This will focus (but not exclusively) on the experience of older people and people with a learning disability or autism, who may have been disproportionately affected by this issue. Doing this will allow CQC to explore how primary, secondary, social care and system partners have worked together in an area – including the impact of commissioning arrangements.

Fieldwork began in November 2020 and a final report is due to publish in early 2021. This is expected to include recommendations on how people can be properly supported in this area and support good practice that protects people’s human rights.