The number of complaints to the Care Quality Commission (CQC) about inappropriate ‘do not resuscitate’ orders soared by more than 300% during the pandemic, an interim report has revealed.
The regulator said in the report, published today, that it identified 40 submissions about do not attempt cardiopulmonary resuscitation (DNACPR) decisions between March and September 2020, compared to nine in the previous six months.
The CQC announced in October that it would review how DNACPR decisions were made during the COVID-19 pandemic, following a request by the Department of Health and Social Care.
Early results of the investigation found DNACPRs may have been used inappropriately when care services were under “extreme pressure” following misunderstanding of the guidance on their use.
The CQC noted that NICE 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.
The majority of complaints to the CQC raised concerns about DNACPR orders that had been put in place without consulting with the person or their family. Often, the evidence received was about an individual, but there were some examples where DNACPR orders were placed on numerous people routinely.
One carer said an on-call doctor 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 CQC has previously said in a statement that it is “unacceptable” for advance care plans, with or without DNAR form completion, to be applied to groups of people “of any description”.
It added that a personalised care plan should always be discussed with an individual directly and, when a person lacks capacity to engage with this processes, it is “reasonable” to produce such a plan following best interest guidelines with the involvement of family members.
The individual feedback the regulator received showed experiences of people and their families who were unaware that they had a DNACPR order, often not finding out until their loved one was unwell.
Sometimes this decision had been made by a medical professional without the involvement of the person or family. In other instances, the family were told that the person had agreed to the DNACPR, but there were questions raised about whether this was informed consent due to reasons such as deafness or not speaking English.
The CQC also stated that it is possible in some instances that inappropriate DNACPRs still remain in place.
Commenting on the report, Rosie Benneyworth, chief inspector of Primary Medical Services and Integrated Care at the CQC 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.
“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.”
The CQC is now undertaking further fieldwork across seven clinical commissioning groups to understand the extent to which DNACPRs may have been misused during the pandemic.
The final report is due to be published in February 2021.
Commenting on the interim findings, Richard Kramer, chief executive of national disability charity Sense, said: “Today’s interim findings by the CQC are concerning but unfortunately don’t come as a surprise as they reflect the worries many of the families Sense supports had at the beginning of the pandemic.
“Disabled people should not be treated as second class citizens and decisions about their health and care should be made in partnership with them and their families. We hope that the CQC will work with organisations like Sense, and disabled people to create greater awareness in healthcare services around complex disabilities. It is vital that health professionals do not make subjective quality of life decisions and that blanket ‘do not resuscitate’ orders become a thing of the past.”
Andrea Sutcliffe, chief executive and registrar at the Nursing and Midwifery Council (NMC), said: “It’s horrifying to hear of DNACPR orders being applied to anyone without their involvement, consent and their individual needs being taken into account. It’s vital that a clear light is shone on this worrying issue through the ongoing work of the CQC’s review.”