A series of recent news stories have drawn attention to health service providers seeking to obtain “do not attempt to resuscitate” (DNAR) forms from some groups of patients en masse. This is clearly against current national policy.
This short briefing clarifies the existing guidance on the use of DNARs and outlines how you can escalate any concerns you pick up locally where this isn’t followed.
What should normally happen?
It is important for people approaching the end of their lives, or at those at increased risk of death due to their medical circumstances, to discuss their care wishes with their family members, carers and clinicians. This is often known as Advance Care Planning.
Advance Care Planning is likely to involve a discussion about the risks and potential benefits of attempting cardiopulmonary resuscitation (CPR), particularly for people at increased risk of cardiac or respiratory arrest. This is because whilst CPR can be lifesaving, it has a low success rate and, even when successful, can lead to severe complications and reduced quality of life.
It is not uncommon for people to agree to a DNAR, which means clinicians will not administer CPR. However, as is made clear in the GMC’s guidance, the completion of a DNAR must always be discussed with the patient (or their representative) and in a sensitive manner.
If a patient is at risk but does not wish to discuss their preferences or lacks capacity to do so, discussion with those close to the patient must be used to guide a decision in the patient’s best interests.
A series of landmark court rulings, most recently in 2015, have affirmed patients’ right to be informed and consulted in relation to decisions to withhold resuscitation under the European Convention on Human Rights (the Human Rights Act in domestic law).
Good practice guidance for conversations around DNAR decisions generally suggests that the conversations should be initiated by a health professional as part of a wider discussion about future care, with individualised timing, participation of family members where desired, and in an appropriate setting.
Response to COVID-19
Healthwatch England is not aware of any significant recent or proposed changes to end of life care policy in relation to the COVID-19 situation. This includes no changes to current guidance on CPR or DNARs.
However, it is understandable that given the increased risk of severe respiratory issues due to COVID-19, services are increasingly promoting Advance Care Planning, including discussing DNARs with patients. This is to ensure people’s wishes are known in case their circumstance changes quickly. This is particularly important where family members are involved, as the current rules around social isolation make this more challenging.
It is worth noting that the decision to withhold CPR is a clinical one in the final instance. If a discussion takes place between a doctor and patient, and a patient does not consent to a DNAR, this does not mean a doctor is legally bound to administer CPR, though patients can request a second opinion. Doctors do not legally require a DNAR to withhold CPR in cases where it has no realistic prospect of success.
To assist in these situations the British Medical Association (BMA) has issued guidance on potential ethical issues surrounding clinical decision-making during the COVID-19 pandemic, and encouraging clinicians to review the appropriateness of CPR for all inpatients.
Clarifying current misinterpretations
As mentioned above, a number of recent media stories have highlighted examples of GP practices and CCGs acting inappropriately and insensitively by asking patients to sign DNAR forms via a letter without prior consultation. This clearly goes against current guidance.
NHS England has now written to all parts of the system to reiterate that such action is not appropriate and stress that at no point should ‘blanket policies’ be used to apply DNARs to any group of patients. This point has already been made in the joint guidance issued by the BMA, Resuscitation Council UK and the Royal College of Nursing.
CQC joint statement on Advance Care Planning
On Monday 30 March, CQC wrote to adult social care providers and GP practices with a statement prepared with the British Medical Association, Care Provider Alliance and Royal College of General Practitioners. The statement sets out their shared position on the importance of advance care planning being based on the needs of the individual.
Action you can take
From discussion with stakeholders and local Healthwatch we have identified the following actions you can take in relation to this issue:
- Promote the purpose and importance of advance care planning through your communication channels. Healthwatch England has produced a new web article to help with this.
- Keep an eye on local conversations around DNARs by engaging with your local ethics advisory groups which will be considering how national guidance is implemented at this time.
- Use the information in this article to help local services understand what the current guidance is on DNARs where you feel it has been misinterpreted.
- If you think you have identified examples where current policy on DNARs is not being followed then raise this with your CCG to take action locally and ensure you inform Healthwatch England so we can escalate with NHS England as necessary.
If you want to discuss this further or share a concern, send us an email.
If you want to follow broader updates on end of life care, Marie Curie have produced a website bringing together a range of existing and new resources.
Planning care at the end of life
Our public advice and information article explains why it’s important to have a plan in place should you or a loved one become critically ill with coronavirus.