Do not attempt cardiopulmonary resuscitation (DNA-CPR) decisions were made without some patients' consent during the early part of the pandemic and were incorrectly combined with other clinical assessments around critical care.
In an interim report from the Care Quality Commission (CQC), early findings are that a combination of unprecedented pressure on care providers led to confusion and misinterpretation of guidance.
It used guidance issued by NICE as an example, which said that all patients on admission to hospital, irrespective of Covid-19 status, should continue to be assessed for frailty using a recognised frailty score such as the Clinical Frailty Scale.
The CQC said that the appropriateness of critical care may have been interpreted as the sole basis for clinical decisions in some instances. Revised guidance was issued five days later to make it clear that this was not an appropriate use of the tool.
The report added that DNA-CPR 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.
While there is no evidence to suggest that blanket approaches to DNA-CPR decisions are being used, the CQC said it was 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 DNA-CPR is now undertaking rapid fieldwork in seven Clinical Commissioning Groups (CCGs) to better understand how DNA-CPRs 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.
DNA-CPR decisions made without some patients' knowledge or consent
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."
She added that all care providers have a responsibility to assure themselves that any DNA-CPR 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.