Inquiry begins into blanket use in England of Covid 'do not resuscitate' orders
An urgent investigation into blanket orders not to resuscitate care home residents has been launched amid fears some elderly people may still be affected by the “unacceptable” practice.
After Covid-19 cases rose slightly in care homes in England in the last week, with 116 residences handling at least one infection, the Care Quality Commission (CQC) said it was developing the scope of its investigation “at pace” and it would cover care homes, primary care and hospitals.
In March and April, there were reports that some GPs had applied “do not attempt resuscitation” (DNAR) notices to groups of care home residents that meant people would not be taken to hospital for potentially life-saving care.
This was being done without their consent or with little information to allow them to make informed decisions, the CQC said. Cases emerged in care homes in Wales and East Sussex.
Care homes said the blanket use of the orders did not appear to be as prevalent ahead of a possible second wave of infections and families were reporting fewer concerns, although that could be because visiting restrictions meant they had less access to the homes and were getting less information.
There are also concerns that steps may not have been taken to review DNAR forms added to care home residents’ medical files, and so they could remain in place, without proper consent. The CQC review will examine the use of “do not attempt cardiopulmonary resuscitation” (DNACPR) notices, which only restrict chest compressions and shocks to the heart.
Dr Rachel Clarke, a palliative care expert in Oxford, has described the CPR process as “muscular, aggressive, traumatic” and said it often resulted in broken ribs and intubation. The review will also investigate the use of broader do not resuscitate and other anticipatory care orders.
“We heard from our members about some pretty horrific examples of [blanket notices] early in the pandemic, but it does not appear to be happening now,” said Vic Rayner, the executive director of the National Care Forum, which represents independent care homes. “DNAR notices should not be applied across settings and must be only used as part of individual care plans.”
It will also investigate the use of broader do not resuscitate and other anticipatory care orders.
The health minister, James Bethell, ordered the review on 1 October, telling parliament the blanket use of do not resuscitate orders was “unacceptable”.
More than 18,000 people died from confirmed or suspected Covid-19 in UK care homes in the first phase of the pandemic. DNARs are often part of care plans anticipating death and allow people to make a shared decision with doctors and family about what intervention they would like in the event of cardiac or respiratory arrest, including refusing resuscitation that can often be painful and dangerous.
In April, the CQC published a joint statement with doctors and care providers, reminding all providers it was unacceptable for advance care plans, with or without DNAR form completion, to be applied to groups of people of any description. The regulator said it would report back before the end of the year, with full findings due in early 2021.
“We welcome this commission from the Department of Health and Social Care and are taking it forward at pace,” said Dr Rosie Benneyworth, the chief inspector of primary medical services and integrated care at the CQC.
“This builds on the concerns we reported earlier in the year and we are pleased that they are being given closer attention … Through this review we will look to identify and share best practice in this complex area, as well as identifying where decisions may not have been patient-centred and ensuring mistakes are not repeated.”
An investigation published this month by Amnesty International included reports of the use of blanket DNARs. It quoted the daughter of a care home resident in Lancashire, who said: “The nurse from the GP surgery rang me up to say they decided Mum is DNR [do not resuscitate]. I asked why and they said: ‘We did this across the home,’ and I said: ‘No, this should be done on individual cases and I don’t agree to it.’”
About one in seven care home residents have dementia or memory loss, according to the Alzheimer’s Society, which described blanket DNARs as “appalling … effectively denying people their right to life, without permission appropriately obtained”.
“These orders must only ever be applied to people on an individual basis, with all the correct checks in place,” said Fiona Carragher, the director of research and influencing at the charity. “It’s vital that the CQC investigation ensures this never happens again, correcting any cases where it may have been inappropriately applied.”