A report published by the Care Quality Commission (CQC) in March 2021 found concerning variations in how ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions have been applied during the pandemic. The CQC found that some people and/or their relatives had not been properly involved in DNACPR decisions, or were unaware that such an important judgement about their care had been made (CQC, 2021).
Background
End-of-life care decisions have featured prominently in the popular and professional press in recent years. For example, readers will remember the demise of the Liverpool Care Pathway (LCP), which had a primary aim of providing, high-quality and dignified care for patients approaching life's end. Although there were many supporters of the LCP, its use in clinical practice fell into disrepute after adverse newspaper headlines demonised its application when families began to complain that their relatives had been put on the LCP pathway without their consent. Furthermore, it was believed death had been hastened in some people on the pathway who were not in danger of dying imminently, through an over-prescription of powerful analgesics (Neuberger et al, 2013; Glasper, 2017).
Similar concerns about hastening life's closure were raised in a 2003 report, which had been commissioned by the then Chief Medical Officer after concerns about the deaths of elderly patients at the Gosport War Memorial Hospital (Baker, 2003). In 2019, a new criminal investigation was launched into the deaths of patients who were given high doses of opiate analgesia at the hospital (Dyer, 2021).
Resuscitation
The purpose of basic life support (BLS) such as CPR is to maintain oxygenation and critical perfusion of vital organs until advanced life support (ALS) becomes available to address the causes of the patient's cardiac arrest. All nursing students are taught BLS in skills laboratories using mannikins during their first semester of training. This is regularly addressed during annual mandatory updating training after registration, which is monitored by the CQC as part of its inspection processes.
Resuscitation of patients is a regular occurrence in hospitals and is co-ordinated through rapid response teams. The application of BLS and ALS is a continuum begun by the ward staff and bolstered by the arrival of the rapid response team. However, Yuen et al (2011) revealed that the average survival rate for all patients undergoing CPR in US hospitals was only 10-15% in the 1980s and stated that this rate had not improved since then. They also highlighted that, for specific groups of patients, such as those with metastatic cancers, survival rates are even lower. Additionally, in many patients who have been successfully resuscitated, complications including rib fractures, permanent neurological deficits and impaired functional status are common. These negative sequelae of successful resuscitation may also include psychological harm that lowers survivors' quality of life.
Many people, especially those approaching life's closure, may not wish to be resuscitated but will certainly want to be involved in any pertinent discussions relating to their views on the subject with healthcare staff.
The universal application of resuscitation procedures results in more harm than good for some recipients and this led healthcare staff to question the appropriateness of CPR in certain situations. Over the past four decades, hospitals have begun to prescribe DNACPR orders for certain patients (Yuen et al, 2011).
The Resuscitation Council UK (RCUK) states that the purpose of a DNACPR decision is to provide immediate guidance to those present (mostly health professionals) on the best action to take (or not to take) should the person suffer a cardiac arrest or die suddenly (RCUK, 2021a). Such DNACPR decisions are taken because it may not be in that person's best interests to be resuscitated and many do not wish to undergo attempted CPR. When a person has a cardiac arrest because they are dying from an advanced and irreversible condition, the application of CPR may deprive them and those important to them of a dignified death. Hence decisions not to attempt CPR that are formulated and recorded in advance serve to guide those present if a person subsequently suffers a cardiac arrest.
A DNACPR order is not legally binding, whereas an advance decision to refuse treatment (ADRT) is a legally binding document (RCUK, 2021a). If the ADRT includes not having CPR a health professional who then subsequently attempts CPR on that person in full knowledge of the valid ADRT would be at risk of a charge of battery.
How are DNACPR decisions made?
There are a number of reasons why a patient may have a recorded DNACPR decision in their medical records. Perhaps the most important reason is that many people may not wish to be resuscitated because they are suffering from a prolonged and debilitating condition. These decisions are not taken lightly and involve a conversation between the patient if they have capacity and/or members of the family and the medical team. Sometimes it might be necessary for the medical team to make a decision on behalf of the patient if that facilitates a peaceful and dignified death. Other treatments and personal care will continue.
Many health professionals now advise the use of a ReSPECT form (a recommended summary plan for emergency care and treatment), which is more comprehensive thaN the DNACPR proforma. It includes a summary of a patient's personalised clinical care in a future emergency, including resuscitation, where they would not have capacity to make or express choices. The ReSPECT form can also be used to draw attention to the presence of an ADRT (RCUK, 2021b).
CQC concerns in the pandemic
Owing to concerns related to the application of resuscitation procedures during the COVID-19 pandemic, the CQC was commissioned by the Department of Health and Social Care to conduct a review of DNACPR decisions (CQC, 2020).
From the outset of the pandemic there were concerns that DNACPR decisions were being applied without proper dialogue with patients and their families or carers. In particular, DNACPR decisions were being applied to groups of people such as those being cared for in nursing homes, rather than taking into account each person's individual wishes. Such blanket orders not to resuscitate some categories of care home residents at the start of the pandemic have concerned many. Mencap, the charity that represents people with learning disabilities, has revealed that it had received reports early in 2021 from people with learning disabilities that they had been told they would not be resuscitated if they became infected with the coronavirus (Tapper, 2021).
The CQC's subsequent report highlighted three key areas that must be addressed to ensure that DNACPR orders are correctly applied and reviewed as necessary (CQC, 2021).
Information, training and support
The CQC was told by some patients that conversations about DNACPR had come out of the blue and that they were not given the appropriate information or the time to comprehend what such a decision entailed. Some patients were unaware a DNACPR decision was in place in their medical records. Certain groups, including those with learning disabilities or elderly patients with dementia, revealed that they were not given information they needed in a format they could understand. The CQC stated that the training and support that staff receive to hold DNACPR conversations is a crucial factor in whether they are able to do so in a person-centred way that meets people's needs and protects their human rights. Clearly, if staff are not fully trained in enabling such conversations with patients and their families, the risk remains of an inappropriate decision being made (CQC, 2021).
A consistent national approach to advance care planning
The CQC stated that there is now a need for a consistent national approach to advance care planning and DNACPR decisions. The consistent use of accessible language, communication and guidance is needed to enable understanding and information sharing among commissioners, providers and the public. This is vital given the wide range of advance care planning proformas in use across the health sector. This lack of consistency could negatively impact on the quality of care being received and result in missed opportunities to support patients and their loved ones in the right way or at the right time.
The large number of acronyms related to end-of-life decisions and use of inaccessible language can be confusing and may prevent people from being fully engaged in conversations about their care. Providers were having to deal with huge amounts of frequently changing information, leading to a lack of clarity (CQC, 2021).
Improved oversight and assurance
The CQC report stated that the health sector and patient representative bodies should now take prompt steps to improve how they ensure that patients and people involved in DNACPR decisions receive personalised, compassionate care. The CQC found pockets of good practice across the sector, but poor record keeping and a lack of audits around the application of these processes made it unclear whether people were being appropriately involved in conversations about DNACPR decisions and whether these were being made on individual assessments.
The CQC also raised concerns about whether DNACPR decisions were reviewed and who had oversight of training and support for health and care professionals to ensure they were making sound clinical decisions that were person-centred and protected people's human rights (CQC, 2021).
Conclusion
The CQC has found worrying variations in people's experiences of the application of DNACPR notices during the pandemic. The report stresses that it is totally unacceptable for blanket DNACPR decisions to be made for any group of patients and that all such decisions must be applied individually and based on personal needs (CQC, 2021).
KEY POINTS
- A report by the Care Quality Commission (CQC) in March 2021 has found a range of concerning variations in how do not attempt cardiopulmonary resuscitation (DNACPR) decisions have been applied during the pandemic
- Survival rates for all patients undergoing CPR are low
- The CQC has stated that it is unacceptable for blanket DNACPR decisions to be made for any group of patients and that all such decisions must be applied individually and based on personal needs