03/12/2020

Today, the Care Quality Commission (the “CQC”) published an interim report as part of its review into the designation of “Do not attempt Cardiopulmonary Resuscitation” (“DNACPR”) and advance care planning during the COVID-19 pandemic, which has been the focus of much attention and criticism in the press.

CQC has made it clear that it expects all providers and local systems to ensure that any discussions and decisions about DNACPR happen as part of person-centred advance care planning, and in accordance with legal requirements.

Following the announcement in October, by CQC, that an investigation would be carried out, Bevan Brittan set out the background to DNACPR notices and their overlap with issues of best interests and a clinician’s duty of care. 

In this article, we explore CQC’s preliminary findings and set out some practical steps that providers might look to take.

Interim Findings

CQC has received evidence indicating unacceptable and inappropriate DNACPR decisions being taken at the start of the pandemic.  Service users and representative groups have reported to it that individuals were designated as DNACPR without their knowledge and consent, and not based on their needs or wishes.

CQC has found that, in the early days of the pandemic, there was confusion and miscommunication about the application of DNACPR and a sense that providers were overwhelmed.  CQC considers that decisions concerning DNACPR may have been incorrectly conflated with clinical assessments around critical care. 

Forward care planning and DNACPR decisions are common practice in many individual circumstances. However, the CQC is clear that they should be put in place with involvement of the individual, or an appropriate representative, and an understanding what they would like to happen as part of their care.    

CQC has indicated that there is no evidence to suggest that blanket approaches to DNACPR decisions are continuing currently. However, the CQC has highlighted its ongoing concern that inappropriate DNACPRs may still be in place.

The CQC’s review continues with the assistance of seven Clinical Commissioning Groups (“CCGs”) to better understand how DNACPRs have been used since the start of the pandemic. The CQC intends to focus its ongoing fieldwork on the experience of older people and people with a learning disability or autism. CQC’s intention is to define good practice and support development of good practice by issuing a clear set of recommendations for all relevant stakeholders. 

CQC’s final report is expected to be published in early 2021.

Practical Steps for Providers

  1. Review existing DNACPR decisions – in line with best practice and responding to this interim report, providers should keep existing DNACPR decisions under review to ensure that they are appropriate, lawful and that they have not been made using a blanket approach.
  2. Review End of Life Care Planning Policies - review internal policies and care plans to ensure they are compliant with the legal framework and clear to clinicians.
  3. Duty of Candour – this duty applies to all CQC registered providers. Providers should be mindful of whether the duty of candour arises where service users may have had an inappropriate DNACPR in place.
  4. Reporting Errors -  providers should have a process for reporting adverse incidents, such as putting in place an inappropriate DNACPR, which includes making referrals to external regulatory schemes/ bodies, including the CQC.  It is crucial that errors are reviewed at an early stage so that lessons can be learnt quickly and service users can be protected from harm in the future.
  5. Internal Review of DNACPRs during COVID – consider whether it would be appropriate to carry out an internal review of the application of DNACPRs during the pandemic (and previously, if there is any concern about historic practices).

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 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.

What’s Coming up?

In our next article on this topic, we will explore the practical considerations in putting in place DNACPRs.

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