A report from the Care Quality Commission (CQC) watchdog on Thursday looked at the scale of do not attempt cardiopulmonary resuscitation (DNACPR) orders in care homes. These orders mean that resuscitation would not be attempted if someone stopped breathing or if their heart stopped.
“In some cases, people were not always aware that a DNACPR decision was in place,” said the report. “We heard evidence from people, their families and carers that there had been ‘blanket’ DNACPR decisions in place.”
This is “potentially discriminatory and unlawful” under the Equality Act 2010.
The report said it is “concerning” that older people, those with dementia and those with learning disabilities said they were “not supported” in care conversations.
The review heard about the experiences of more than 750 people. Over 500 residents had been subject to a DNACPR order. But the real figure will be much higher, as most care providers didn’t respond to the CQC survey.
The CQC sent a voluntary information request to around 25,000 adult social care providers. It received just 2,048 responses.
The CQC also spoke to individuals about their experiences of care during the pandemic. Melanie’s father Jim was taken to hospital at the start of the pandemic with a chest infection. He was in his 80s.
Jim called Melanie “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,” the report said. “He was upset that he had agreed to it because he didn’t want to die.”
Other people felt pushed to agree with orders being put in place. “I felt pressured to accept the decision of the doctors as they illustrated a terrible picture (immense suffering of the person) if I did not,” said one.
Several discovered the orders by accident. “I only found out when they were discharged from hospital,” one respondent told the CQC. “It was a tremendous shock.”
“The first we knew about it was a letter from the hospital after my father had been discharged,” said another. “No conversation was had with us or my father.”
The CQC’s public survey found that 30 percent of people with a DNACPR in place hadn’t been aware of it. Some 28 percent of relatives or carers also said they were not aware of the orders.
The providers that responded to the CQC said around a third of orders applied in March were still in place last December.
Some people felt conversations about whether they would want to receive cardiopulmonary resuscitation “came out of the blue”. “They were not given the time or information to fully understand what was happening,” said the review.
It found a “worrying picture of poor involvement, poor record keeping, and a lack of oversight and scrutiny of the decisions being made”.
Without these “we cannot be assured that decisions were, and are, being made in line with the person’s wishes and human rights”.
There was a “concerning disregard for disabled people”. Blanket DNACPR orders were imposed on people with learning disabilities “who are not near the end of their lives”.
And the number of people in nursing homes subject to the orders shot up after coronavirus hit last March.
In one care home, bosses imposed a DNACPR order on every resident over 80 who had dementia. The Covid-19 Bereaved Families for Justice group said this is “shocking and terrible”.
“These are people who were in a frail and vulnerable position who weren’t given a chance,” it said.
The CQC said that there was “increased pressure” on staff due to the pandemic and conversations about people’s care were often rushed.
People working in adult social care settings “felt overwhelmed, overloaded and unsupported in raising concerns”.
“In many cases it was not clear who to raise concerns with,” it said. “Some people told us that care providers had challenged blanket DNACPR decisions, but they felt no one was listening.”
Privatisation has created a fragmented care system with privately-run homes that are seen as businesses rather than a service. Prioritising profit means cutting corners on training and has also driven down pay and conditions for workers, which then harms the quality of care.
The CQC found that the “training and support” given to workers was a “key factor” in how residents are treated.
“We were concerned that where health and care workers, particularly in care homes, did not have the training they needed, they would not be able to identify concerns or issues,” it said. “They may not see it as their responsibility to challenge an inappropriate DNACPR decision or feel confident in raising concerns.
“This means that people may not be protected from unsafe care or treatment, and may be at risk of having their human rights breached.”
The report didn’t explicitly identify privatisation as a factor in the care people receive. But it did say the “lack of consistent approach created challenges” for staff, confusion and more work.
“These factors could all impact on the quality of care received,” it said.
Good practice “was not always rolled out” across local areas. “This meant there may have been missed opportunities to support the whole local population more effectively.”
It could also mean “mistakes” that put people “at risk of unsafe care or treatment or neglect and harm”.