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CQC finds that combination of increasing pressures and rapidly developing guidance may have contributed to inappropriate advance care decisions
The Care Quality Commission (CQC) today publishes an interim report from its review into the application of do not attempt cardiopulmonary resuscitation (DNACPR) decisions during the COVID-19 pandemic. Early findings are that at the beginning of the pandemic, a combination of unprecedented pressure on care providers and other issues may have led to decisions concerning DNACPR being incorrectly conflated with other clinical assessments around critical care.
As one example of the pressure and confusion at the time, CQC noted that guidance intended to help clinicians assess frailty as part of a wider, holistic assessment around the appropriateness of critical care may have been interpreted as the sole basis for clinical decisions in some instances.
In this case, the misinterpretation was quickly acknowledged, and revised guidance was issued five days later to make it clear that this was not an appropriate use of the tool.
DNACPR decisions and advance care plans should only ever take place with clear involvement of the individual, or an appropriate representative, and a clear understanding of what they would like to happen.
While there is no evidence to suggest that blanket approaches to DNACPR decisions are being used currently, people who use services and groups that represent them told CQC that early in the pandemic they or their loved ones received DNACPR decisions which were not based on their wishes and needs, and without their knowledge and consent.
It is unacceptable for decisions to be applied to groups of people of any description.
However, differing views remain as to whether people are now receiving appropriate, person-centred care and support around this issue and CQC’s review continues. CQC’s review into the use of DNACPR is now undertaking rapid fieldwork in seven Clinical Commissioning Groups (CCGs) to better understand how DNACPRs have been used since the start of the pandemic and what good practice looks like. Further consideration is needed and the next stage of this work will be vital in identifying what local systems need to do so they can protect against possible future errors.
Rosie Benneyworth, Chief Inspector of Primary Medical Services and Integrated Care at the Care Quality Commission said:
“It is unacceptable for clinical decisions – decisions which could dictate whether someone’s loved one gets the right care when they need it most – to be applied in a blanket approach to any group of people.
“Sadly, in the experiences that people have generously shared with us there is very real concern that decisions were made which not only overlooked the wishes of the people they affected, but may have been made without their knowledge or consent.
“As we warned in our recent State of Care report, these findings highlight that inequalities in the care people receive risk being magnified by the impact of the coronavirus pandemic. As this is such an important and sensitive issue, we have worked quickly to share these interim findings and we will continue this work so that we build on the evidence already shared and can make recommendations for the future. It is vital that we look at what happened on the ground, continue to speak to people using services and people working in them, so that we can make sure that the health and care system learns the crucial lessons it needs to from this difficult time.
“We have also highlighted the fact that it is possible in some cases that inappropriate DNACPRs remain in place – and made it clear that all care providers have a responsibility to assure themselves that any DNACPR decisions have been made appropriately, in discussion with the person and in line with legal requirements.”
These interim findings have provided a base for the fieldwork currently underway in seven CCGs across the country. This will focus (but not exclusively) on the experience of older people and people with a learning disability or autism, who may have been disproportionately affected by this issue. Doing this will allow CQC to explore how primary, secondary, social care and system partners have worked together in an area – including the impact of commissioning arrangements.
Fieldwork began in November 2020 and a final report is due to publish in early 2021. This is expected to include recommendations on how people can be properly supported in this area and support good practice that protects people’s human rights.
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- Last updated:
- 03 December 2020
Notes to editors
- Person-centred advance care planning, which may include the use of DNACPR decisions, is an important tool to help people have important conversations and record what matters most to them about the care they receive.
- In October 2020, The Department of Health and Social Care asked CQC to review how Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were used during the coronavirus pandemic, building on concerns that CQC reported earlier in the year.
To look at a range of ways of working and experiences, seven areas have been selected for fieldwork as part of CQC’s review:
- NHS Birmingham and Solihull CCG
- NHS Bristol and North Somerset CCG
- NHS Cambridge and Peterborough CCG
- NHS Morecambe Bay CCG
- NHS Sheffield CCG
- NHS South East London CCG with a focus on Greenwich
- NHS Surrey Heartlands CCG with a focus on East Surrey
As well as taking into account the information shared with us, these CCGs have been selected to cover a cross-section of areas and a mix of demographics so that the lessons we learn will be of value to people in health and social care across the country, wherever they are working.