DNR orders may still be in people's care home files without agreement

Doctors may have made blanket decisions about “no resuscitation orders” during the first wave of the pandemic without input from patients or their families, the care dog warned.

The Care Quality Commission (CQC) said the number of complaints it had received about orders without cardiopulmonary resuscitation (DNACR) rose to 40 between March and September.

There were only nine similar complaints in the past six months.

Inappropriate DNACPR notices could still be in people’s files, the CQC said.

Initial results from the CQC’s investigation revealed that DNACPRs may have been used inappropriately when healthcare services were under extreme pressure due to misunderstanding of the guidelines for their use.

Only 15% to 20% of those undergoing the highly invasive hospital resuscitation procedure survive, and the survival rates drop to between 5% and 10% outside of a hospital setting.

While it can cause leaky lungs, broken ribs and severe bruising, not fully assessing a patient or their loved ones is a violation of their human rights, the CQC warned.

CQC guidelines state that decisions about DNACPRs should never be dictated by general policy, should be free from discrimination, and should not be made on the basis of a physician’s “subjective view of a person’s quality of life”.

Despite reminding caregivers of their obligations, the CQC said it had received evidence from patient personnel and relatives that DNACPR orders had been applied without consultation.

A caregiver said a doctor on duty had informed the nursing home staff that if a resident were given Covid-19, a DNACPR warrant would automatically be introduced.

Another witness said that some nursing homes and learning disability services had been ordered by general practitioners to issue general orders to all under their care.

Others said they said it was unclear how and to whom to escalate concerns.

A senior nursing home staff member said that staff had successfully challenged any inappropriate DNACPR order they were aware of, but this had been difficult and the clinicians ignored their concerns.

Some families of patients said they were not made aware of such an order until their relative was quite unwell.

Others said they had been told their loved one had agreed to a DNACPR order, but were concerned about their understanding due to factors such as lack of English or deafness.

The CQC also found examples of routine care not provided at home, such as an ambulance or a doctor not being called due to the existence of an order not to resuscitate.

It added that the Nice guidelines to clinicians on March 20 on considering co-morbidities and other underlying health concerns when assessing vulnerability and DNACPR orders may have been misinterpreted.

While the advice was clarified just five days later, the CQC said it may not be picked up “quickly or universally.”

The CQC is now conducting further fieldwork with seven clinical assignment groups to gain insight into the extent to which DNACPRs may have been misused during the pandemic.

The final report will be published in February 2021.

Rosie Benneyworth, Superintendent of Primary Medical Services and Integrated Care at the CQC, said: “It is unacceptable for clinical decisions – decisions that can determine whether a loved one receives the right care when they need it most – to be put in a blanket. approach a group of people. “

She added: “It is vital that we look at what happened on the ground, keep talking to people who use services and those who work there, so that we can ensure that the health and care system learns the crucial lessons who needs it. this difficult time. “

A spokeswoman for the NHS said: “ The NHS has repeatedly instructed local clinicians that the widespread use of DNRs would be completely unacceptable and that access to treatment and care for people with learning disabilities and autism should always be on an individual basis and in consultation with family. . and caretakers. “