DNACPR Notices: CQC Publishes Final Report

The Care Quality Commission (CQC) has released its final report into the use of ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions during the coronavirus pandemic. The background on this topic can be found in our article here as well as our commentary on the Interim Report here.

Findings

The CQC’s report highlighted differences in people’s experiences of DNACPRs and raises some serious concerns. The report focused on three key themes:

1. Information, training and support
2. Consistent national approach to advance care planning
3. Improved oversight and assurance

Information, training and support

Experiences of DNACPR decisions varied. Some people felt involved in the decision-making process, as part of a discussions about their care. However, others felt that conversations around cardiopulmonary resuscitation (CPR) came out of the blue and that they were not given the time or information to fully understand what was happening. In some cases, people were not even aware that a DNACPR decision was in place.

The CQC expressly highlighted concerns around whether staff had the right knowledge or skills around the Mental Capacity Act and making Best Interest decisions. The CQC are concerned that people in some groups, like older people, people with a learning disability or people with dementia, were not being given the information they needed in a way they could understand, or were not being supported to talk about DNACPR decisions. The training and support that staff received to hold these conversations was a key factor in whether they were held in a person-centred way. Without training and information there is a clear risk of inappropriate decision making and a risk of unsafe care or treatment. It also raises concerns that people’s human rights and rights under the Equality Act 2010 had not been considered or were at risk of being breached.

Whilst the CQC found providers on the whole did not report the “blanket” use of DNACPR, they did find evidence from some families and carers of DNACPR decisions being in place for groups of people, not for each person as they should be used, particularly at the start of the pandemic. This raises a clear risk of discrimination.

Consistent national approach to advance care planning

The CQC found many types of advance care planning in use nationally. These included ReSPECT plans, local treatment escalation plans and DNACPR decisions. These models use different approaches and different types of forms and documentation. This lack of consistency and the problems this causes could affect the quality of care for individuals.

Improved oversight and assurance

The CQC found poor record keeping and a lack of audit which meant that they could not always be assured that people were being involved in conversations about DNACPR decisions, or that these were being made on individual assessments.

Once DNACPR decisions were in place, it varied whether providers and local systems reviewed them.

The CQC expressed particular concern where DNACPRs were put in place without discussion with the person, their relative or carer and had not been reviewed since the CQC’s interim report. Because the majority of people in adult social care are disabled and/or over 65 these DNACPRs are at risk of breaching individual’s human rights and rights under the Equality Act 2010.  

Recommendations

The CQC has made recommendations and named specific organisations and stakeholders to lead on those recommendations. These recommendations will be very important considerations for our clients across the independent and public health and social care sector.

The report is clear that DNACPR decisions need to be recognised as part of wider conversations about advance care planning and end of life care and these decisions need to be made in a safe way that protects people's human rights.  The CQC confirmed that the National Institute for Health and Care Excellence (NICE) are developing a new guideline on how to make shared decision making part of everyday care in all settings. The guide will promote ways for health and care professionals and people using services to work together.

Information, training and support

Providers must ensure people are always at the centre of their care, including advance care planning and DNACPR decisions. Providers must ensure that individuals and/or their representatives are included in compassionate, caring conversations about DNACPR decisions. This includes making adjustments to remove information or communication barriers. Providers must also make sure that their staff have sufficient time to engage with people.

Integrated care systems must ensure access to equal and non-discriminatory personalised support around DNACPR decisions that supports their human rights. They must consider diversity, inequality and mental capacity factors when planning care for the local population, in partnership with local communities.

Providers, Health Education England, and Skills for Care need to give clear and consistent training, standards, guidance and tools for clinicians and professionals. This needs to be in line with a national, unified approach to DNACPR decision making.

Consistent national approach to advance care planning

DHSC, NHS England and NHS Improvement should lead in supporting individuals, their families and representatives in personalised care: education around their rights; and how to challenge decisions; promotion of advance care planning; and a national campaign to publicise accessible information.

NHSX and integrated care systems should ensure digital compatibility between providers, enabling real-time updates and information sharing (including DNACPR decisions) between professionals, services and sectors.

Improved oversight and assurance

CQC have highlighted an urgent need for regional health and care systems, including providers, clinical commissioning groups and patient representative bodies, to improve how they assure themselves that people are experiencing personalised, compassionate care in relation to DNACPR decisions.

Providers must ensure comprehensive records of conversations with, and decisions agreed with, people, their families and/or representatives. This means having standards of documentation and record keeping and sharing of information around the system.

Integrated care systems need to be able to monitor the quality and safety of DNACPR decisions using consistent data sets and metrics across areas.

The CQC will focus on DNACPR decisions through monitoring, assessment and inspection of all health and adult social care providers. Providers should carefully consider this ahead of future inspections of their services. Practical steps for providers can be found in our last article on this topic, here. 

CQC has recommended that a new Ministerial Oversight Group be set up to explore the issues raised in their report. The group, which they suggest should include health, social care, local government and voluntary and community services, should be responsible for overseeing the delivery and required changes of the recommendations of the report.

We can help

Bevan Brittan have extensive and recent experience in advising public/independent health and social care providers in DNACPR notices and policies. We also provide training and support to clients around the Equality Act, the Mental Capacity Act and Best Interest decision making. We can provide practical support to your organisation with any of the points discussed in this article.  For more information on how we can help you, please feel free to get in contact with one of our team.