DNACPR Decisions: concerns over a lack of understanding by care providers

A recent inquest decision has once again brought Do Not Attempt Cardio Pulmonary Resuscitation (“DNACPR”) decisions into focus for care home providers. Providers will no doubt be aware that there is an increased focus at this time on the application of DNACPR decisions by the CQC, which has recently published its review of DNACPR decisions during the pandemic. The findings of this report highlighted the need for greater training on DNACPR decisions by providers and improved oversight and assurance.

In a recent inquest, the Senior Coroner for East Sussex made a Regulation 28 Report to Prevent Future Deaths (PFD) after a resident at a nursing home died having choked on his breakfast. The Coroner concluded that an ambulance, wrongly, was not sent because the resident had a DNACPR decision in place. The Coroner expressed concern that no-one involved in the incident (from the 999 call operator to the registered nurse at the nursing home) understood the circumstances when it may not be appropriate to apply a DNACPR decision. It was the view of the Coroner that action should be taken to ensure that there is training and clarification to prevent a similar incident occurring again in the future. The PFD has been sent to the Association of Ambulance Chief Executives and the Nursing and Midwifery Council who must respond to the Coroner with details of action taken or proposed to be taken, or an explanation of why no action is proposed. A copy has also been sent to the CQC.

This is a worthwhile opportunity to remind care providers of the guidance surrounding DNACPR decisions.

Usually, a DNACPR decision is put in place where a person has indicated that they would not want to receive Cardio Pulmonary Resuscitation (“CPR”), or where it is considered that CPR would be likely to be futile, or that the potential disadvantages associated with CPR outweigh the potential advantages. The DNACPR is not intended to be a blanket decision in respect of attempting CPR (unless of course there is a valid and applicable advance decision to refuse CPR in all circumstances), but is a tool to aid clinical decision making about CPR. The DNACPR does not relate to other care or treatment.

Having a DNACPR in place does not mean that CPR should never be attempted. General Medical Council guidance and guidance from the British Medical Association (BMA), the Resuscitation Council (UK) and the Royal College of Nursing is clear that absent a valid and applicable advance decision to refuse CPR, the DNACPR should not be automatically applied where the cause of the respiratory or cardiac arrest is readily reversible and/or does not match the circumstances envisaged when the DNACPR was made and recorded. The examples of a reversible cause given in BMA guidance are: choking, a displaced tracheal tube, or a blocked tracheostomy tube. It should be made clear to the person at the time of the decision that the DNACPR would usually only apply in the context of an expected deterioration/trigger leading to the requirement for resuscitation or a sudden cardiorespiratory arrest and may not apply to an unforeseen and potentially reversible event such as a blocked airway. It is important that workers, individuals and those close to them properly understand this point to ensure DNACPR decisions are applied correctly and to seek to prevent deaths.

This reminder comes at a time where there is a renewed spotlight on care providers and a lack of understanding of the use of DNACPR decisions. The CQC recently published its review of the use of DNACPR decisions during the coronavirus pandemic following concerns that decisions were being made without involving people, or their families and/or carers if so wished, and were being applied to groups of people rather than taking into account each person’s individual circumstances. Whilst it did not find that there had been a national blanket approach to DNACPR, there was “undoubtedly confusion at the outset of the pandemic and a sense that some providers felt under pressure to ensure DNACPR decisions were in place.”

The CQC concluded that changes are needed to ensure conversations concerning DNACPR decisions are person-centred, meet people’s needs, protect their human rights and rights under the Equality Act 2010, and to prevent inappropriate decision-making and unsafe care or treatment. 

The CQC’s findings can be found here, but in short there is a need for providers of care to:

• ensure that people and/or their representatives are included in conversations about DNACPR decisions and have the opportunity to engage with clinicians, health professionals and care workers
• provide clear and consistent training, standards, guidance and tools for the current and future workforce. Now may be an appropriate time for refresher training and/or to review your DNACPR policy.
• keep comprehensive records of conversations with and decisions agreed with people, their families and/or representatives

DNACPR decisions, in and of themselves, are tools to assist clinical and professional decision-making and are not binding in all circumstances.

For further information on this topic see our other article DNAR notices: is blanket application possible? or please contact us to discuss further:

• Hannah Taylor
• Amelia Bauer