Older people need answers on inappropriate use of DNACPR
Over the course of the first lockdown, many of us felt increased levels of anxiety as we experienced huge changes to our everyday lives. Older people have been one of the groups who have been worst affected by the pandemic. One of the main issues Age Scotland encountered during this period was the inappropriate use of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions.
In March and April last year, our helpline received a high number of calls from angry and worried older people who had been contacted “out of the blue” by their GP practice, often by non-clinical staff, and asked to consent to a DNACPR form. A DNACPR form is added to a person’s medical records when clinicians judge that attempting CPR may not work or may cause them more harm. While DNACPR plays an important role within Anticipatory Care Planning, national guidance states there should be a sensitive and open conversation with patients, and where appropriate, their families, about it. Although clinicians will use their judgement to decide whether to make a DNACPR decision, this discussion between patient and clinician should always take place, and both parties should be well informed about it in advance.
The large-scale process of contacting – it would seem – older people at the height of the first wave made people feel their lives were worth less than someone younger. It is also important to remember that these inadequate conversations were taking place against a backdrop of concerns at the time about access to medical treatment for older people if they became unwell with Covid-19.
We stopped hearing of as many inappropriate DNACPR cases in mid-May, but our helpline did hear about occasions of poor practice ahead of the winter season and even more recently into 2021.
There are considerable questions about whether individuals’ human rights were breached when DNACPR decisions were made without appropriate and sensitive discussions taking place.
Age Scotland heard about numerous cases of poor practice, including:
- occasions where DNACPR forms had been slipped into hospital discharge notes without a patient’s knowledge – even after they had explicitly said they did not want one.
- calls made to people living with dementia, excluding their Power of Attorney, who have no recollection of agreeing to the DNACPR.
- occasions where all residents in some care homes had DNACPR orders applied to them unilaterally, without consultation.
- examples where a GP’s opening question was about whether loved ones or spouses would be able to cope without the call recipient.
Age Scotland's Response
We have repeatedly raised this issue in the media and with the Scottish Government directly. At several points, we have called for an inquiry into the use of DNACPR during the pandemic.
We first raised the issue with the Scottish Government in April last year and received assurances that they had not proactively asked GPs to change their approach to DNACPR. The Scottish Government then wrote to GP practices to provide advice on Anticipatory Care Planning conversations and to make clear that there is no requirement for health professionals to raise DNACPR as part of this. The Scottish Government also publicly confirmed there was no change to guidance on the use of DNACPR forms during the pandemic – both in publications and during the First Minister’s televised briefings at the time.
Our Head of Policy and Communications provided evidence to the Scottish Parliament’s Equalities and Human Rights Committee about the issue in May 2020. You can read the Official Report of the session here. Our evidence on DNACPR is highlighted in a report published by the Committee in March 2021 about the wider impact of the pandemic on equalities and human rights issues. We also signed a joint statement with similar organisations from across the UK about this issue which was published on the 6th April 2020.
Ahead of the winter season, Age Scotland submitted freedom of information requests to health boards in Scotland about the use of DNACPR orders. We asked them to provide information about the use of DNACPR in 2019 and 2020, including an age breakdown of the patients involved. However, information on DNACPR is only stored within individuals’ medical records.
Following this, we wrote to the Scottish Parliament’s Health and Sport Committee in November to ask MSPs to investigate the use of DNACPR orders. We asked the Committee to look into the scale of the issue; whether there were specific criteria for people to be approached; where it started and how the practice spread; and how many people had DNACPR orders applied without their knowledge.
Due to constraints on the Committee’s time ahead of the Scottish parliamentary election they were unable to hold an inquiry, but we hope DNACPR will form part of a future inquiry into the Scottish Government’s handling of the pandemic – which the Government has already agreed to hold.
Most recently, we called on Healthcare Improvement Scotland to undertake an inquiry into the use of DNACPR during the pandemic. We took this step after the publication of an investigation by the Care Quality Commission, the care watchdog in England, which found the human rights of over 500 patients may have been breached when DNACPR orders were applied to their patient file without a discussion.
The use of DNACPR during the pandemic has been a source of distress for many older people. Additionally, as a result of media coverage we secured highlighting the issue, several older people contacted us to make us aware of their negative experiences of DNACPR from before the pandemic. We believe guidance on DNACPR must be updated to improve public awareness of and confidence in DNACPR and Anticipatory Care Planning processes more widely. More needs to be done to reassure people that their human right to medical treatment is absolute.
We believe there should be an investigation into the improper use of DNACPR during the pandemic. Patients and their families must be provided with answers and reassurances these experiences will not happen again in future. The Scottish Government has already said it will hold a human rights-based inquiry about the response to Covid-19 and we would like to see this wider inquiry include consideration of DNACPR. We have also urged Healthcare Improvement Scotland to examine if DNACPR has been used in inappropriate and ageist manner which has infringed on individuals’ human rights – and to recommend how it could be improved going forward.