Imagine that death is just around the corner. How will you spend your final moments? Quietly with loved ones? With a priest giving last rites? Perhaps listening to your favourite music? Or how about being subjected to 300-joule electric shocks while your ribs are broken, undergoing a medical procedure that is unlikely to succeed?
Cardio-pulmonary resuscitation (CPR) is an emergency procedure that can save lives – although less often than your favourite TV drama might suggest. It rightly forms a central part of standard first aid courses and clinical training. But as well as knowing how to use CPR, medics also need to know when not to use it – an issue more pertinent than ever as the pandemic has hit care homes with tremendous force.
Whether or not to perform CPR is no easy decision. Several factors have to be taken into account: How fit and healthy is the patient? What is the chance of success of CPR in this patient, right now? How likely are adverse clinical outcomes, such as brain damage? And does this patient even want CPR?
This decision is often – and ideally – made before an emergency arises. A Do Not Attempt CPR (DNACPR) order is used to let medical professionals know they should not attempt the procedure. This should be an individualised decision, made and recorded in consultation with the person in question.
It should reflect not only their specific medical situation, but also their personal beliefs, values and wishes. For example, someone may prefer to accept death rather than resort to heroic medical measures. This information then informs a “now or never” decision about whether to resort to CPR or not.
But as with so many things at present, COVID has potentially created a problem here. A new report from the Care Quality Commission (CQC) has revealed that the pandemic may have increased improper use of DNACPR orders in care homes.
Upsurge during pandemic
The report shows that DNACPR orders have become more common during the pandemic: the percentage of nursing home residents with an order in place rose from 74% to 92% from March to December 2020.
According to the report, 71% of people with a DNACPR decision in place told the CQC they felt completely or mostly supported to participate in a conversation about this decision and 70% said they felt completely or mostly listened to and able to speak up. While that is not a perfect record, it shows that patients can and do feel empowered by conversations surrounding these orders.
But the report also raises significant concerns. Almost half the respondents to the public survey felt they had been discriminated against or treated unfairly during the DNACPR process. Some 6% of adult social care providers told the CQC that “blanket” DNACPR decisions had been made – meaning they were applied across the board rather than on the basis of individual assessment and consultation.
These figures may point to poor practice and serious violations of anti-discrimination and human rights laws (for example the right to life).
The CQC report provides some much needed insight into the use of DNACPR orders during the pandemic. But it also leaves a number of important questions unanswered. Why did DNACPR orders became more common? Why were “blanket” decisions made, and how?
The report focuses mainly on how DNACPR orders are adopted and pays little attention to how they are being interpreted and used. Yet scrutiny about their interpretation and use is also important.
As the name suggests, a DNACPR order refers to cardio-pulmonary resuscitation only: it is a narrowly defined medical instruction. It does not apply to other forms of resuscitation – rehydration, for example, or the treatment of shock. Much less does it apply to other forms of care. That’s why it’s dangerous to use shorthands like DNR (Do Not Resuscitate) or DNAR (Do Not Attempt Resuscitation), which wrongly suggest a broader application.
But are DNACPR orders being used within these boundaries? Or are there forms of mission creep whereby a DNACPR order is used to limit care more broadly? The CQC report mentions anecdotal evidence that one person with a DNACPR order in place was denied treatment altogether, but does not provide further information about the issue.
Our new study may shed light on some of these unanswered questions, picking up where the CQC report left off. The research we are doing at the Essex Autonomy Project, focuses on human rights in locked down care homes. Initial findings from an ongoing online survey suggest that 19% of care professionals working in or with care homes during the pandemic witnessed DNACPRs influencing medical decisions beyond CPR.
It’s imperative that we understand how COVID-19 has affected the use of DNACPR orders – to ensure everyone gets a say in decisions about their own life and death, but also to help care staff deal with these difficult decisions under the heightened pressures of the pandemic.
This article was written with the assistance of Vivek Bhatt, with research support provided by Emily Fitton. Financial support was provided by the Arts and Humanities Research Council; Grant Number AH/V012770/1: Ensuring Respect for Human Rights in Locked-Down Care Homes.
Wayne Martin's research is supported by the Arts and Humanities Research Council and the Wellcome Trust.
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