CQC finds “worrying variation” in DNACPR decisions

WORRYING variation in the use of do not attempt cardiopulmonary resuscitation (DNACPR) decisions during the pandemic has been identified by the Care Quality Commission (CQC) in a new report.

Protect, respect, connect – decisions about living and dying well during COVID-19 calls for the establishment of a Ministerial Oversight Group – working with partners in health and social care, local government and the voluntary sector – to take responsibility for delivering improvements in how DNACPR decisions are made.

The Department of Health and Social Care had asked the CQC to conduct a rapid review of how DNACPR decisions have been used during the coronavirus pandemic, citing concerns that they were being inappropriately applied to groups of people without their knowledge. DNACPR decisions should not be made without proper conversations with the individual, or an appropriate representative, taking into account their wishes and needs.

An interim report published in December 2020 found that a combination of unprecedented pressure on care providers and rapidly developing guidance may have led to decisions concerning DNACPR being incorrectly conflated with other clinical assessments around critical care. This latest report draws on fieldwork in seven Clinical Commissioning Groups (CCGs), responses to a national information request to providers of adult social care, a national public survey and ongoing engagement with voluntary sector organisations working in the area.

The CQC found that most providers of adult social care, primary care and secondary care reported they were not aware of inappropriate DNACPR decisions, or decisions being applied to groups of people, but it did receive some feedback that "blanket" DNACPR decisions had been proposed at a local level. The regulator also heard examples of these being quickly challenged and retracted.

Examples of good practice were found but also a "worrying picture" of poor involvement of people using services, poor record keeping, and a lack of oversight and scrutiny of the DNACPR decisions. CQC makes it clear that shortfalls in governance must be addressed if providers are to assure themselves that decisions are, being made on an individual basis and in line with personal wishes and human rights.

Rosie Benneyworth, Chief Inspector of Primary Medical Services and Integrated Care at the Care Quality Commission said: "Personalised and compassionate advance care planning, including DNACPR decisions, is a vital part of good quality care. Done properly, it can offer reassurance and comfort for people and their loves ones – before and during difficult times.

"It is vital we get this right and ensure better end of life care as a whole health and social care system, with health and social care providers, local government and the voluntary sector working together.

"Covid-19 has brought this to the fore but these are not new issues. While this rapid review was not asked to make judgments on how decisions might have impacted individual cases, we have to take this opportunity to address these problems. We need to make sure that people have the opportunity to discuss their wishes about care and treatment in a compassionate and person-centred way."