Certain care homes were told by NHS leaders not to resuscitate seriously ill residents at the peak of the coronavirus pandemic, a new report has found.
The report, about the effect of the pandemic on care homes, said some unnamed GPs, hospitals and clinical commissioning groups (CCGs) sought to impose the policy without care homes even needing to consult patients’ families.
It also described how some healthcare leaders looked to introduce the “do not resuscitate” orders for entire care home populations at the height of the outbreak in March and April – when pressure on healthcare was at its greatest amid fears the NHS would not cope with the outbreak.
Some nurses challenged the advice as “unethical”, the report, published by the Queen’s Nursing Institute (QNI) charity on Monday, added.
The findings were based on surveys from 163 care home nurses and managers across the UK. While only a clear minority – 16 – raised concerns with “do not resuscitate” advice given to them, report author Professor Alison Leary said these cases remain “worrying”.
Prof Leary told Yahoo News UK: “It’s quite worrying there were decisions made without full discussion: either with families, patients or care home staff.”
What is a ‘do not resuscitate’ decision?
“It’s about not offering a certain kind of treatment when it’s probably going to be futile,” Prof Leary explains. “For people that are very, very unwell, where the cause of their death is not reversible, you wouldn’t generally offer resuscitation as a treatment option.”
According to the Resuscitation Council UK, it is not in everyone’s interest to be resuscitated. Cardiopulmonary resuscitation (CPR), the charity explains, subjects people to “vigorous physical intervention” that can deprive them of a dignified death and in some cases, prolong suffering.
Prof Leary, who is a professor of healthcare and workforce modelling at London South Bank University, adds: “Just because you don’t offer resuscitation, it doesn’t mean you don’t offer treatment. It might be about controlling people’s symptoms, helping people staying comfortable.”
Why would healthcare leaders advise ‘do not resuscitate’ without family consultation?
That’s currently unknown, and why Prof Leary thinks this small number of cases is worrying.
“Ideally [the decision is] with the patient and the family, depending on the patient’s wishes.
”It’s certainly something that unless there are circumstances when a patient can’t consent, if they are extremely unwell, the practice would be to consult with the patient and the family.
“For about 10% of people who responded to our survey, those conversations weren’t happening. Different people who perhaps hadn’t seen those residents in those care homes were saying ‘don’t resuscitate these people’.”
She adds: “It could have been for very legitimate reasons but the responders to our survey felt it wasn’t always so. They felt it was a blanket decision that was being made and that made them challenge those decisions.”
The Department of Health was on record last month as saying “it is completely unacceptable for DNACPR [do not attempt cardiopulmonary resuscitation] orders to be applied in a blanket fashion to any group of people”.
Yahoo News UK has approached NHS England for comment about the report’s findings about “do not resuscitate”, but has not received a response.
What did care home staff themselves say?
Here are some excerpts from the report:
“We were advised to have [DNACPR] in place for all residents. We acted in accordance with medical advice and resident wishes, not as advised by a directive to put in place for all by a CCG representative. We challenged this as unethical.”
“Sometimes changed without inclusion of family or the resident (where appropriate). Not always made including quality of life rather than disease and age.”
“Put in place without family consent by trust staff, no consultation with staff in home.”
While 16 care home staff reported negative experiences around “do not resuscitate”, 39 people said the pandemic forcing them to have conversations about end-of-life care planning had a positive impact.
“For some people it has acted as a catalyst to make time for that difficult conversation,” Prof Leary says.