Ensuring Person-Centered DNACPR Decisions During the Pandemic

 
DNACPR – 
Protect, respect,
connect – decisions about living
and dying well during COVID-19
 
Dr Rosie Benneyworth, Chief Inspector of Primary Medical Services
and Integrated Care
 
DNACPR Decisions: Ensuring Effective and Person-Centered Practice
15 September 2021
 
1
 
Our role and purpose
 
T
he Care Quality Commission is the
independent regulator of health and
adult social care in England
We make sure health and   social
care services provide people with
safe, effective, compassionate,
high-quality care and we encourage
care services to improve
 
2
 
3
 
DNACPR review: an overview
 
In October 2020, the Department of Health and
Social Care (DHSC) asked CQC to review how Do
Not Attempt Cardiopulmonary Resuscitation
(DNACPR) decisions were used during COVID-19
We made our position clear on how DNACPR
decisions should be made at the beginning of the
pandemic
We published an interim report in Dec 2020
based on intelligence received from people
sharing their experience, stakeholder groups
and reviewing existing guidance
This is the final report
 
Our review of DNACPR decisions during
the pandemic
 
4
 
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Jim’s story
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Jim was in his 80s
Jim still worked
Jim had normally been fit, well and active
Jim had a daughter called Melanie
Jim went out most weeks in his car to visit friends or go to the cinema.
Jim was taken to hospital at the beginning of the pandemic after becoming unwell with a
chest infection
 
5
 
Melanie told us that she tried to speak to the medical and nursing staff about this decision.
 
She felt that:
 
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However, she was concerned that her dad was vulnerable because he was ill, likely to be confused as he
had a bad infection, and he was all alone.
 
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Jim died while in hospital. Not being allowed to visit because of the pandemic, and the way in which the
DNACPR was applied, made his death even more distressing for Melanie and her family.
 
Jim’s story
 
6
 
DNACPR review: 
Themes
 
Concerns raised as part of our scoping
exercise were confirmed through
fieldwork
A mixed picture around blanket and/or
inappropriate use of DNACPRs
Poor record keeping means that it has not
been possible to verify the extent of the
problem
Information,
training and
support
Consistent
national
approach
Improved
oversight
and
assurance
 
Themes
 
7
 
Increased pressure on staff time and resource
People were involved in decision making but evidence
that:
people were not always supported
there had been ‘blanket’ DNACPR decisions in place
people were not supported in advance care planning
conversations, or given the information they needed
in an accessible way
There was a lack of awareness and confidence among
people, families and care workers about what a
DNACPR decision meant, and how to challenge this
 
DNACPR review: 
Summary of findings
 
Summary
 
of findings
 
8
 
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
.
Integrated care
systems need to be
able to monitor and
assure themselves of
the quality and safety
of DNACPR decisions
DNACPR decisions need to be
recognised as part of wider
conversations about advance
care planning and end of life
care. These decisions need to
be made in a safe way that
protects people’s human rights
R
e
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a
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e
 
People must
always be at the
centre of their
care
Everyone needs to
have access to
equal and non-
discriminatory
personalised support
Clinicians, professionals
and workers must
have knowledge,
skills and confidence
to speak with people and
families
Support is needed for
people to understand
what good practice looks
like for DNACPR
decisions
Professionals and patients
need support so they all
share the same
understanding and
expectations for DNACPR
decisions
People need to
have more positive
and seamless
experiences of care
Health and social
care providers must
ensure that all
workers understand
how to speak up
There must be
comprehensive
records of
conversations and
agreed decisions
CQC must continue to seek
assurance that people are at the
centre of personalised, high-
quality and safe experiences of
DNACPR decisions
R
e
s
p
o
n
s
i
b
l
e
:
 
C
a
r
e
 
Q
u
a
l
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t
y
C
o
m
m
i
s
s
i
o
n
 
Recommendations
 
9
 
Dr Rosie Benneyworth
Chief Inspector
Primary Medical Services and Integrated Care
 
www.cqc.org.uk
enquiries@cqc.org.uk
 
 
@CQCProf
youtube.com/user/cqcdigitalcomms
facebook.com/CareQualityCommission
 
Thank you and any questions?
 
10
Slide Note

DHSC has asked CQC to review how Advanced Care Planning (including Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) and Do Not Attempt Resuscitation (DNAR)) decisions were used during the coronavirus pandemic

Earlier in the year, concerns were widely reported that elderly and vulnerable people may be being subjected to blanket decisions without their consent or with little information to allow them to make an informed decision

In April 2020, we published a joint statement with the British Medical Association (BMA) Care Provider Alliance (CPA) and Royal College of General Practitioners (RCGP), reminding all providers that it is unacceptable for advance care plans, with or without DNAR form completion to be applied to groups of people of any description

Early findings show 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 combined with other clinical assessments around critical care

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This article discusses the importance of making effective and person-centered decisions about DNACPR during the COVID-19 pandemic. It highlights a case study involving Jim, an elderly man, and his daughter Melanie, emphasizing the need for involving family members in such critical decisions to ensure the patient's wishes are respected and understood. The Care Quality Commission's role in overseeing health and social care services to provide compassionate and high-quality care is also emphasized.


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  1. DNACPR Protect, respect, connect decisions about living and dying well during COVID-19 Dr Rosie Benneyworth, Chief Inspector of Primary Medical Services and Integrated Care DNACPR Decisions: Ensuring Effective and Person-Centered Practice 15 September 2021 1

  2. Our role and purpose The Care Quality Commission is the independent regulator of health and adult social care in England We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve 2

  3. Our review of DNACPR decisions during the pandemic DNACPR review: an overview In October 2020, the Department of Health and Social Care (DHSC) asked CQC to review how Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were used during COVID-19 We made our position clear on how DNACPR decisions should be made at the beginning of the pandemic We published an interim report in Dec 2020 based on intelligence received from people sharing their experience, stakeholder groups and reviewing existing guidance This is the final report 3

  4. Jims story About Jim Jim was in his 80s Jim still worked Jim had normally been fit, well and active Jim had a daughter called Melanie Jim went out most weeks in his car to visit friends or go to the cinema. Jim was taken to hospital at the beginning of the pandemic after becoming unwell with a chest infection About 12 hours after being admitted to hospital Jim called Melanie. He was upset and confused, and told her he had signed away his life and was going to die. He told her that a doctor had put an order in place that they wouldn t restart his heart if it stopped. He was upset that he had agreed to it because he didn t want to die. 4

  5. Jims story Melanie told us that she tried to speak to the medical and nursing staff about this decision. She felt that: The conversations were all one way No one asked about her dad, about what he was like and what his life was like at home Because Jim was able to make decisions about his care, no one had discussed the decision with her However, she was concerned that her dad was vulnerable because he was ill, likely to be confused as he had a bad infection, and he was all alone. She felt he would have just gone with what they told him. Jim died while in hospital. Not being allowed to visit because of the pandemic, and the way in which the DNACPR was applied, made his death even more distressing for Melanie and her family. 5

  6. Themes DNACPR review: Themes Concerns raised as part of our scoping exercise were confirmed through fieldwork A mixed picture around blanket and/or inappropriate use of DNACPRs Poor record keeping means that it has not been possible to verify the extent of the problem Information, training and support Consistent national approach Improved oversight and assurance 6

  7. Summaryof findings DNACPR review: Summary of findings Increased pressure on staff time and resource People were involved in decision making but evidence that: people were not always supported there had been blanket DNACPR decisions in place people were not supported in advance care planning conversations, or given the information they needed in an accessible way There was a lack of awareness and confidence among people, families and care workers about what a DNACPR decision meant, and how to challenge this 7

  8. 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. 8

  9. Recommendations Clinicians, professionals and workers must have knowledge, skills and confidence to speak with people and families People must always be at the centre of their care Everyone needs to have access to equal and non- discriminatory personalised support DNACPR decisions need to be recognised as part of wider conversations about advance care planning and end of life care. These decisions need to be made in a safe way that protects people s human rights Professionals and patients need support so they all share the same understanding and expectations for DNACPR decisions Support is needed for people to understand what good practice looks like for DNACPR decisions People need to have more positive and seamless experiences of care Responsible: Department of Health and Social Care CQC must continue to seek assurance that people are at the centre of personalised, high- quality and safe experiences of DNACPR decisions Integrated care systems need to be able to monitor and assure themselves of the quality and safety of DNACPR decisions Health and social care providers must ensure that all workers understand how to speak up There must be comprehensive records of conversations and agreed decisions Responsible: Care Quality Commission 9

  10. Thank you and any questions? Dr Rosie Benneyworth Chief Inspector Primary Medical Services and Integrated Care www.cqc.org.uk enquiries@cqc.org.uk @CQCProf youtube.com/user/cqcdigitalcomms facebook.com/CareQualityCommission 10

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