Blanket Do Not Attempt Resuscitation orders

3.12 It is unacceptable for advance care plans, including Do Not Attempt Resuscitation orders, to be applied in a blanket fashion to any group of people, and CQC have been urgently contacting providers where this practice has been brought to their attention. Everyone at risk of losing mental capacity or nearing the end of their life should be offered the opportunity and supported, if they wish, to develop advance care planning that make their wishes clear, and to make arrangements, such as lasting power of attorney for health and social care decisions, to put their affairs in order. This must always be a personalised process.

Here are some examples of blanket Do Not Attempt Resuscitation (DNACPR) orders in England:

1. Care home in Lancashire: Reports emerged of a blanket DNACPR order being applied to all residents in a care home, without individual assessment or consultation with patients or families.
2. Care home in East Sussex: An investigation found that a blanket DNACPR order was applied to all residents over 80 with dementia, without individual consideration.
3. Reports from care homes: A survey of care home staff revealed 16 respondents reported blanket DNACPR orders, leading to hospital admission being refused. The Queen’s Nursing Institute reported blanket DNACPR instructions from GPs, CCGs, or hospitals without discussion with residents, families, or care homes. Worryingly some nurses raised serious ethical and professional concerns, for example GPs, Clinical Commissioning Groups and hospital trusts making resuscitation decisions without first speaking to residents, families and care home staff or trying to enact ‘blanket’ ‘do not resuscitate’ decisions for whole groups of people.
4. GP surgery in Lancashire: A family reported receiving a phone call from a GP surgery nurse stating that a blanket DNACPR order had been applied to all residents in the care home, without prior discussion or consent.

These examples illustrate the concerns raised about blanket DNACPR orders being applied without individual consideration, leading to potential denial of access to care and potentially life-saving treatment. The Care Quality Commission (CQC) and NHS England subsequently investigated and emphasized the importance of personalized decision-making regarding DNACPR orders.

It’s essential to note that these examples are based on reports and may not represent a comprehensive or representative sample of all instances of blanket DNACPR orders in England. However, they do highlight the concerns and controversies surrounding this issue during the COVID-19 pandemic.

The Queen’s Nursing Institute (QNI) reported instances where blanket Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) instructions were issued by GPs, Clinical Commissioning Groups (CCGs), or hospitals without discussion with residents, families, or care homes. This practice was deemed unacceptable and potentially unlawful.

Examples of Poor Practice

• GPs completing cursory DNACPR forms for every resident in a care home without any discussion with the individuals or their relatives.
• Hospitals and CCGs issuing blanket DNACPR decisions for groups of people without considering individual circumstances or consulting with care home staff.
• Care homes not being consulted or involved in DNACPR decision-making processes, leading to a lack of understanding and potential disagreement with the decisions.

Concerns and Impact

• The QNI’s findings raised concerns about the potential for discriminatory and unlawful use of DNACPR forms.
• The practice may have resulted in unjustified denial of medical treatment, including CPR, to individuals who could have benefited from it.
• The blanket approach may have disproportionately affected older and disabled people living in care homes, including those with physical and sensory impairments, learning disabilities, or cognitive impairments such as dementia.

Recommendations

• Healthcare professionals should ensure that DNACPR decisions are made on an individual basis, taking into account each person’s wishes, needs, and circumstances.
• Care homes and families should be involved in DNACPR decision-making processes and consulted before any decisions are made.
• Healthcare providers should ensure that DNACPR forms are completed in accordance with best practice and applicable laws, such as the Mental Capacity Act 2005.