The Care Quality Commission (CQC) have been asked by the Department for Health and Social Care (DHSC) to conduct a formal review into how do not attempt cardiopulmonary resuscitation (DNAR) decisions are being used.
What is a do not attempt cardiopulmonary resuscitation (DNAR) decision?
DNAR also know as DNACPR (do not attempt cardiopulmonary resuscitation). They are advance decisions made not to attempt Cardiopulmonary Resuscitation (CPR) on a person, if they later need it. They are usually made when someone’s long term health is unlikely to improve, so if their heart stops there should be no attempts to restart it.
The CQC are reviewing the use of DNAR decisions during the pandemic
The CQC announced in October that the DHSC have asked them to conduct a formal review into the use of DNARs during the pandemic.
This comes after the CQC published a joint statement, in April, to remind practitioners that advance care plans should only be made on an individual basis; they should not apply to any group of people. The joint statement was made by:
- The British Medical Association (BMA)
- The Care Provider Alliance (CPA); and
- The Royal College of General Practitioners (RCGP)
The need arose after reports of elderly and vulnerable people were being asked to sign DNARs, seemingly on a blanket basis, just because they fit a certain criteria. This is contrary to the GMC’s guidance, which says that “decisions about whether CPR should be attempted must be based on the circumstances and wishes of the individual patient”.
It’s reassuring to see that the DHSC has asked the CQC to conduct a formal investigation. The CQC anticipate reporting their interim findings later this year, with a full report to follow in early 2021.
The benefits of DNAR decision
A DNAR is an advanced decision, also known as an advanced decision to refuse treatment (ADRT), or a ‘living will’. It is different to an advanced statement. It should set out any treatment that a patient does not want to receive, in the event that you are unable to say for yourself, when the time comes. As well as CPR, the NHS give ventilation and antibiotics as examples of treatment you could refuse.
Only about two out of every ten people who have CPR in hospital survive, and go on to leave hospital. And if CPR takes place outside of hospital, the rate is half of this. An individual’s chance of survival will be lower or higher depending on their circumstances; but some people will have no chance of surviving.
Even for survivors it’s not all positive. The following injuries are all recognised consequences of CPR:
- Fractured ribs
- Damage to internal organs; and
- Brain damage
Some people will even need high-intensity medical support and some will need to stay in intensive care for a period of time.
This is why some people with certain conditions decide they do not want CPR.
A problem of informed consent
David Oliver, a consultant in geriatrics and acute general medicine, recently wrote in the British Medical Journal on the issue. He said that “Even before covid-19, DNAR orders featured in many a misunderstanding or formal complaint”.
He thinks that conveying some key messages to the public could improve the situation.
- Making it clear that a decision not to attempt resuscitation is not the same as a decision not to provide treatment.
- Setting clear expectations on the chance of survival.
- Ensuring that patients are aware of the unintended consequences of CPR; physical damage and the need for subsequent medical treatment.
- Utilising advance care planning. This will improve patients’ end of life experience and ensure that their decision, along with their doctors advice, is recorded in their medical records.
But is this issue with DNARs indicative of a more insidious issue surrounding informed consent? We live in a world now where you don’t need textbooks and teachers to learn about your illness, so patients are becoming well-informed about their conditions. In turn this means they’re less likely to simply accept decisions made on their behalf, without a logical rationale behind the decision.
David Oliver’s suggestions in respect of DNARs are undoubtedly positive steps in the right direction. The question is whether similar suggestions could apply more widely to other areas of medicine. It took the pandemic to highlight issues with advance care planning. Let’s hope we can solve other problems without the need for a global catastrophe.