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Why were Do Not Resuscitate orders imposed on Care Home Residents?

The Care Quality Commission’s report into the way “do not resuscitate” orders have been used during the pandemic makes appalling reading for those who work in the Health and social care sector. Let’s no beat about the bush here, providers and doctors are fully aware of recognised best practice in end of life care and who should be involved in making decisions about DNACPR (Do not attempt cardiopulmonary resuscitation).

A survey conducted by the regulator found that 30 per cent of individuals with a DNACPR (Do not attempt cardiopulmonary resuscitation) in place weren’t aware of it. The same was true of 28 per cent of relatives and/or carers.

Lack of awareness

The CQC found that most providers of adult social care, primary care and secondary care that they spoke to, reported they were not aware of inappropriate DNACPR decisions, or DNACPR decisions being applied to groups of people, CQC received feedback from stakeholders, people who use services and their families and carers, that ‘blanket’ DNACPR decisions had been proposed at a local level.”

What happened to joined up health and social care decision making?

The report reveals that 119 adult social-care providers felt they had been subjected to blanket “do not attempt CPR” decisions, imposed by GPs upon all their residents, since the start of the pandemic. Hundreds more such decisions were made without any prior discussion with patients or their families – a clear breach of both the law and best practice.

The notion of doctors making lofty life-and-death decisions without deigning first to discuss them with the minions they concern is deeply unnerving. If doctors’ intentions really are benign and uncontentious – based around the harms and benefits of a particular treatment – why would they choose not to share them?

Might those judgments be less about the clinical efficacy of CPR and more about whether the life of a patient with dementia or disability is deemed to be worth living? Are they, in short, playing God: choosing who “deserves” the chance of resuscitation, according to the presumed quality of their life?

Involving all those that matter in the decision

At Bettal Quality Consultancy our policy requires providers to involve everyone who is part of the person’s life. The following is an extract from our policy: Where senior staff and healthcare professionals are discussing and communicating CPR decisions to Service Users and, and those close to them, they should: • Offer as much information as wanted (with due regard for the Service Users wishes concerning confidentiality). • Be open and honest. • Use clear, unambiguous language. • Use a combination of verbal discussion and printed information. • Provide information in formats which people can understand; this may include the need for an interpreter or easy-to-read formats. • Provide information that is accurate and consistent. • Check understanding. • Where possible, communicate decisions in an appropriate environment and allow adequate time for discussion and reflection.

The Bettal policy is based on The Resuscitation Council (UK) guidelines.

Ethical issues

The report states poor DNACPR decisions that put people’s human rights at risk have long been an issue in England. This has been a particular concern in relation to people who are disabled (including people with physical disability and people with a learning disability) and/or older people.

We can’t make the pandemic an excuse We are all aware that the pandemic has put service providers under severe and unprecedented pressure. However, we can’t allow this to become a catch-all excuse for bad practice, and that phrase is utterly inadequate for the blanket placing of “do not resuscitate” orders on people who want to live, and have expressed the desire to do so.

The CQC has done a great service in highlighting all these concerns. The only way for the medical profession to address suspicion and mistrust around “do not attempt CPR” is with openness and candour.

Summary

This CQC report has unearthed alarming human rights issues in social care services. It is disingenuous to put the blame at the door of the pandemic. The blanket approach by the medical profession and others on ‘do not attempt cardiopulmonary resuscitation’ raises ethical questions on how much we value human life.

It is not up to the medical profession to play god on decisions about who should live. No wonder people who are disabled including people with physical disability and people with a learning disability and/or older people are concerned. The CQC must now accept a much wider role. Not only safeguarding and protecting people who use social care services from abuse but the protection of life itself. Albert Cook BA, MA & Fellow Charted Quality Institute Managing Director Bettal Quality Consultancy

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