CQC finds “worrying variation” in DNACPR decisions during Covid-19

On 18 March 2021 the regulator published Protect, respect, connect – decisions about living and dying well during Covid-19 following its review of how DNACPR decisions were used during the coronavirus pandemic. This new report is a follow up to the CQC’s interim report published in December 2020 which found that a combination of rapidly developing guidance and pressure on care providers may have led to decisions concerning DNACPR being conflated with other decisions around critical care.

CQC noted that, since the start of the pandemic, there have been particular concerns that DNACPR decisions were being applied to groups of people rather than taking into account each person’s individual circumstances. They did not find there had been a national blanket approach to DNAPCR but they did find that 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. They felt that this risked undermining public trust and confidence in the health and care system and demonstrates the need for better oversight of DNACPR decisions.

The CQC’s findings indicate a need for focus in three areas with recommendations aimed at ensuring:

DNACPR decisions need to be recognised as part of wider conversations about advance care planning and end of life care, and these decisions need to be made in a safe way that protects people’s human rights.”

As part of this, they explain that a new Ministerial Oversight Group must be set up to look in depth at the issues raised in this report and be responsible for overseeing the recommended changes. The group will be drawn from health, social care, local government and the voluntary and community services. The Department of Health and Social Care will take on the lead responsible body for this action.

We set out below the three areas and note who the lead responsible body is for each – a lot on everyone’s to do lists:

1. Information, training and support

  • People must be at the centre of their care, including advance care planning and DNACPR decisions
    • Lead responsible body: Providers
  • Everyone need to have access to equal and non-discriminatory personalised support around DNACPR decisions, that supports their human rights.
    • Lead responsible body: Integrated care systems
  • Clinicians, professionals and workers must have the knowledge, skills and confidence to speak with people about, and support them in making DNACPR decisions.
    • Lead responsible body: Health Education England, Skills for Care and providers

2. A consistent national approach to advance care planning

  • People, their families and representatives need to be supported, as partners in personalised care, to understand what good practice looks like for DNACPR decisions.
    • Lead responsible body: Department of Health and Social Care and NHS England and NHS Improvement
  • People, their families and/or representatives, clinicians, professionals and workers need to be supported so that they all share the same understanding and expectations for DNACPR decisions.
    • Lead responsible body: Department of Health and Social Care
  • People need to have more positive and seamless experiences of care, including DNACPR decisions, when moving around the health and care system.
    • Lead responsible body: NHSX and integrated care systems

3. Improved oversight and assurance

  • There must be comprehensive records of conversations with, and decisions agreed with, people, their families and representatives that support them to move around the system well.
    • Lead responsible body: Providers
  • Integrated care systems need to be able to monitor and assure themselves of the quality and safety of DNACPR decisions.
    • Lead responsible body: Integrated care systems
  • Health and social care providers must ensure that all workers understand how to speak up, feel confident to speak up and are supported and listened to when they speak up.
    • Lead responsible body: National Guardian’s Office
  • CQC must continue to seek assurance that people are at the centre of personalised, high-quality and safe experiences of DNACPR decisions, in a way that protects their human rights.
    • Lead responsible body: CQC

One of the chapters covers Leadership, Governance and Assurance. It makes the following points which are worthy of note for leaders of both providers and commissioners:

  • Advance care planning, end of life care and DNACPR decisions were often not sufficiently high on the agenda at a system level, and leaders lacked oversight of DNACPR decisions.
  • Providers and commissioners could not always demonstrate how they were assured of the quality of DNACPR decisions.
  • While we found evidence of learning from incidents at local provider level, there was minimal evidence of learning being shared across areas. A lack of evaluation and oversight also meant that it was difficult to say how effective any learning from incidents had been in improving people’s experiences.
  • Leaders of providers and clinical commissioning groups told us that clinicians, professionals and workers knew how to challenge DNACPR decisions but had never been challenged themselves or had records of complaints and concerns.

Do get in touch if you would like to discuss any of the issues raised here or require support with training or your DNACPR policies to ensure your processes and procedures stand up to scrutiny of the decisions being made.

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